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 Vale’s 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 Union’s investigation, Vale officials refused to be interviewed by
members of the USW Team; dozens of USW members cooperated fully in
management’s 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.

Calling it a potential conflict of interest, Steelworkers Local 6500 has asked the premier to exclude Sudbury MPP and Northern Development and Mines Minister Rick Bartolucci from the province's review of the union's report on the deaths of two Vale workers.

The March 30 letter from the union's president, Rick Bertrand, to Premier Dalton McGuinty, said Bartolucci should not be involved because of a conflict of interest relating to his daughter's job at Vale.

Jason Chenier and Jordan Fram were killed at Vale's Stobie Mine June 8, 2011 after being buried by a run of muck from an ore pass.

In the wake of the report's release in late February, a report which blames the company for the incident, the union asked Ontario's deputy attorney general to investigate whether charges should be laid against Vale and its managers.

The union is also asking the province to launch a public inquiry into mine safety in Ontario, with regards to water management issues and the need for inspections by the presence of Ministry of Labour investigators in large mining operations.

“Shortly following the release of our report ... Rick Bartolucci issued a statement and/or made a public comment about our report, responding to media inquiries,” the March 30 letter from Bertrand to Premier Dalton McGuinty stated.

“While the Honourable Minister's comments were innocuous — he had just received the material — Mr. Bartolucci did suggest that he was or would be involved in some way in considering the USW report, the criminal investigation requested, the ongoing MOL investigation, etc., having regard to ministerial responsibilities.

“Under normal circumstances, where Vale was not the subject employer, we would take no issue. Fatalities at an Ontario mining facility are surely something within the concerns of the Minister of Northern Development and Mines, who is also the local MPP.

“However, where the employer is Vale Canada Limited, there are some other considerations affecting the incumbent minister that are cause for concern.”

The letter goes on to say that Bartolucci's daughter is Angie Robson, manager of corporate affairs for Vale's Ontario operations, who frequently appears as the company's “face” and “speaks” for the company.

“We are very concerned that the involvement of the Honourable Minister in any way in the ongoing investigation and considerations by your government, even making bland comments respecting the ongoing investigation that pertain to his daughter's employer, exposes the appearance of a conflict of interest.”

The letter asks that Bartolucci “have no involvement of any kind whatsoever in any consideration by any branch of the government of Ontario into and touching upon the June 8, 2011 events at Stobie Mine, including by your office and by the cabinet.”

Bartolucci's assistant, Adrian Kupusic, said in an email that the MPP would not be commenting on the issue.

Sunday April 8th, 2012 (10:30am – 2pm)

PLEASE CALL FOR RESERVATIONS – BOB RITCHIE 705-675-3381 ext. 252


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SAO PAULO, March 19 (Reuters) - Brazil's Vale , the world's largest iron ore producer, stopped its train line servicing the Carajas mine due to the collapse of a bridge over the Mearim River in the state of Maranhao, according to a securities filing on Monday. (Reporting by Reese Ewing and Roberto Samora)

(TORONTO, ON) -- Ontario Federation of Labour President Sid Ryan accused multinational mining corporation, Vale, of whitewashing an internal investigation into a 2011 double fatality at its Stobie Mine in Sudbury. A separate investigation conducted by the United Steelworkers (USW) that was released today found evidence of company negligence warranting a criminal investigation.

“From the outset, Vale tried to restrict investigations into the tragic incident, refusing to cooperate with the union and demanding control over findings and recommendations. Then, surprise, surprise, the company authored a report in January that declared that no one was to blame,” said OFL President Sid Ryan. “Vale has gone to incredible lengths to bury the facts and cover its tracks. It is only because of the hard work of the United Steelworkers that the truth is beginning to come to light.”

“It seems like the only way to convince Vale to put worker safety ahead of production targets is to escort company officials out of their offices in handcuffs,” said OFL Secretary-Treasurer Nancy Hutchison, herself a former miner who suffered from occupational disease. “There have been four fatalities at Vale mines in Canada in under a year yet no charges have been laid under the criminal code. It is time for the law to crack down on corporate greed that puts lives at risk.”

Without the cooperation of management, USW Local 6500 conducted a separate investigation into the deaths of workers Jason Chenier and Jordan Fram in a flood of mud, rock and ore on June 8, 2011. This investigation revealed that the company had ignored documented concerns about excess water levels and failed to abide by provincial and internal safety requirements. Less than seven months later, two more workers died in Vale mines in Sudbury and Thompson, Manitoba. The OFL today supported the USW’s call for a public inquiry into the safety of Stobie and other Ontario mines and a ministerial committee to review current health and safety legislation and enforcement.

The OFL launched its “Kill a Worker, Go to Jail” campaign after the December 24, 2009 scaffold tragedy at a west-end Toronto building. The campaign calls for criminal code investigations into all workplace fatalities. In 2003, the Criminal Code was amended through Bill C-45 (known as the Westray Bill) to include special criminal negligence provisions for companies that disregard the health and safety of workers. The intent was to hold employers criminally liable for the deaths of workers, but no convictions have been made in Ontario since the law came into effect.

“In Ontario, an average of 80 workers are being killed on the job every year. There have been over 500 deaths since the Criminal Code was changed and not one employer has been convicted.” said Ryan. “How many more workers will have to die before justice is done and greedy bosses are sent to jail?”

The Ontario Federation of Labour (OFL) represents 54 unions and one million workers in Ontario. OFL President Sid Ryan is the voice of Ontario’s labour movement.

Table of Contents
1. Introduction
2. General Information
2.1 Glossary
2.2 Mine Location and Mine History Frood/Stobie Complex
2.3 Mining Methods
2.4 #7 Ore Pass
2.5 Description of Accident Area/Scene
3. Investigation of Accident
3.1 Accident Notification
3.2 Investigation Organization
3.3 Investigation process
3.4 Interviews
4. Description of Accident
5. Work place Conditions/Practices
5.1 #3715 Ore Pass
5.2 # 7 Ore pass design
5.3 Crash Gate Operation
5.4 Bypassing of Material #7 O.P.
5.5 Water management Drainage and Maintenance
5.6 Water Accumulations #3715 and #7 ore pass
5.7 Load Haul Dump (LHD) Bucket design
5.8 “Muck” Conditions
5.9 Blasting Ore Passes
5.10 Ore Pass Blast holes
6. Safety Tools
6.1 SAF 079
6.2 General Safety and Hazard Alerts
6.3 Guardrails and Signage
6.4 Vale Policy and Procedures
6.5 SafeProduction
6.6 Supervisor Log Book
6.7 Internal Responsibility System/ Hazard Assessment and Work Refusals
7. Historical Mine Facts
7.1 1996 Clifford Bastien Coroner’s Inquest
7.2 Historical Water management
7.3 “Run of Muck” Accidents and Incidents
8. Training
8.1 Chute Operation
8.2 Impounding Water and “Wet Muck”
8.3 Periodic Reviews
8.4 Secondary Blasting
9. Joint Health and Safety Committee (JHSC)
10. Discussion
10.1 #3715 Ore Pass
10.2 #7 Ore Pass
10.3 Crash Gate Operation/Bypassing of Material #7 O.P.
10.4 Water management, Drainage and Maintenance
10.5 #7 Ore pass Water Accumulations
10.6 Load Haul Dump (LHD) Bucket design
10.7 “Muck” Conditions
10.8 Ore Pass Blasting
10.9 Ore Pass Blast holes
10.10 SAF 079 Injury/ Incident/ Unsafe Condition Recording and Investigation
10.11 General Safety and Hazard Alerts
10.12 Guardrails and Signage
10.13 Vale Policy and Procedures
10.14 SafeProduction
10.15 Supervisor’s Log Book
10.16 Internal Responsibility System/ Hazard Assessment and Work Refusals
10.17 Historical Mine Facts
10.18 Training on Chute/Ore Pass Pulling
10.19 Training for Impounded Water/”Wet Muck” Awareness
10.20 Periodic Reviews
10.21 Secondary Blasting
10.22 JHSC Committee
11. Cause of Accident
11.1 Root Cause of Double Fatality
11.2 Contributing Causes to the Double Fatality
11.3 Management and Organizational failures
12. Violations of Rules, Regulations, Policies and Standards
12.1 Ontario Occupational Health and Safety Act
12.2 Mines and Mining Plants P.R.O 1990 Regulations 854
12.3 Company Standards
1. Vale All Mines Standards (AMS)
2. Violations of Vale Employee Handbook Policies and Procedures
3. Violations of Vale SafeProduction-Zero Harm
13. Criminal Code of Canada
14. Recommendations
15. Appendixes
A. Persons participating in the Investigation
B. Victim Profiles
C. Sequence of Events
D. Ontario Health and Safety Act and Regulation 854
E. Vale Policies and Procedures
F. Procedures
G. Drainage Plan
H. Radio Logs
I. SAF 079’s
J. SPI 079
K. Training Documentation
L. Work Refusal Flow Chart
M. Document Requests
N. Interviews
O. E-mail Summary
P. General Safety Organization (GSO)
Q. CBA Schedule J Worker Safety Representatives
R. Presidents USW Local 6500 Investigation Media Release
S. Blast Hole Information
T. Joint Health and Safety Documentation
U. Mine Rescue Notes
V. 1996 Clifford Bastien Coroner’s Inquest
W. Terra Probe Report
X. Supervisor Log Books
Y. Prodstats
Z. Geology Report 2450 L 3722URM Stope
AA. Miscellaneous Photos
BB. Photos of Water Accumulations
CC. Photos of the 3000 Level
DD. Photos of Inside #7 Ore Pass
EE. Photos of Blast Holes
FF. Video of #7 Ore Pass
GG. Video of #4407 Blast Hole
HH. Hoist Schedule
II. Drawings of Control Stations
JJ. Drawings and Photos of LHD Buckets
KK. Drawings of Mine and Ore Passes
LL. Ministry of Labour Field Visits
MM. Unusual Occurrence Report
NN. Video Simulation and Miscellaneous
OO. Hazard Alert E-mail
PP. CMS of 3000 Level Control Station
QQ. Criminal Code Of Canada
RR. Mining Methods
SS. Glossary


1. Introduction
On Wednesday, June 8th, 2011 at approximately 9:45 p.m., Vale employees, Jason Chenier and Jordan Fram were both fatally injured at the Vale Frood/Stobie Complex in Sudbury, Ontario. The fatalities occurred during the third shift of a four night shift rotation at Stobie Mine’s #7 ore pass on 3000 Level.

Jason Chenier, aged 35, was a Supervisor, with 11 years of service at Vale. Jordan Fram, aged 26, was an Hourly Worker, with 6 years of service at Vale.

The two were fatally injured when a “run of muck” (an un-controlled release of water, blasted rock, ore, and sandfill) occurred at the #7 ore pass control station located on Stobie Mine’s 3000 Level. The material violently exited the ore pass and inundated the area that the two men were occupying. As a consequence, the material engulfed and fatally injured the two men. This double fatality occurred after months of continual issues with #7 ore pass and #3715 ore pass. Shortly after the fatalities, excessive water accumulation was noticed on 2400 Level, 2450 Level, 2600 Level, 2800 Level and 3000 Level in the mine.

At approximately 10:00 p.m. another employee traveling through the area discovered the scene. The employee called for assistance and a rescue effort was undertaken by employees and Mine Rescue personnel. Both employees were recovered and pronounced dead at the scene by the coroner.

The scene was secured. Police, Ministry of Labour (MOL) , Vale Company Officials and United Steelworkers (USW) Local 6500 were notified. Independent initial investigations commenced by the various parties.

2. General Information

2.1 Glossary

Air cannon – a device that blows a blast of air into an ore pass to help move material.

ALARA, SLAM, PHR, PHA, HAZOPS – Are safety acronyms used by the company in the SafeProduction program.
ALARA – As Low As Reasonably Achievable
SLAM – Stop Look Asses Manage
PHR – Process Hazard Review
PHA – Process Hazard Analysis


All Mines Standards (AMS) – Is a document that is intended to be used as a reference by, and accessible to, all mine employees to identify the minimum acceptable standards that must be adhered to in the workplace. The standards contained in this document enhance the Ontario Health and Safety Act and the Regulations for Mines and Mining Plants that apply in the province of Ontario and provide the minimum mandatory requirements to be followed in each mining plant.

Blasting – The act of using explosives to remove material in mining.

Blast (shock) Concussion - A large-amplitude compression wave, as that produced by an explosion.

Bypass – movement of material from one point to another, usually in order to make room for other material to enter the system/ore pass.

Chute - An inclined passage for the transfer of material to a lower level in an underground mine.

Crash Gate – Usually made of steel, used to control the movement of material in an ore pass chute by blocking the ore pass chute.
Cushion (in an ore pass) – An engineered calculation requiring an amount of material be in an ore pass. This calculation is based on the length of the ore pass and the surrounding rock types. A cushion has two purposes: 1) to prevent the sides of the ore pass from failing, 2) eliminate impact and wear on crash gate installations from dumping of material.

Draw Point - An underground opening at the bottom of a stope or ore pass through which broken ore is extracted.

Drift - A horizontal underground opening that follows along the length of a vein or rock formation as opposed to a crosscut which crosses the rock formation.

Equal – A computer based system used by the company that tracks employee qualifications.

Fly Rock -The fragments of rock thrown and scattered during quarry or tunnel blasting.

Foot Wall - The rock on the underside of a vein or ore structure.

General Safety Office (GSO) – an independent group that functions mostly in an advisory role. The GSO’s role includes the identification and communication of incidents and related hazards. The GSO has a service level agreement with the Mines and Works department of Vale.

Grizzly - A grating, usually constructed of steel rails, placed over the top of a chute or ore pass for the purpose of stopping large pieces of rock or ore that may hang up in the pass.

Guardrail – a device that protects against underground hazards. A guardrail must be secure and clearly visible. The standards for the installation of guardrails are set out in All Mines Standards, Chapter 22.

Hang Up – slang term for material blocking the movement of other material in and ore pass or draw point.

Hanging Wall - The rock on the upper side of a vein or ore deposit.

Hazard Alert – A document used by the company to communicate various workplace, equipment or situational hazards to employees or other affected parties.

Hydraulic Power Pack – Equipment used to provide the means to open and close the Crash Gate at the #7 ore pass control stations.

Impounded Water –Specific to an ore pass. A water accumulation within an ore pass where water collects above material in the ore pass.

Internal Responsibility System - The internal responsibility system puts in place an employee-employer partnership in ensuring a safe and disease free workplace. A health and safety committee is a joint forum for employers and employees working together to improve workplace health and safety.

Inundate – Inundated - To cover with water, especially floodwaters.

Joint Health and Safety Committee (JHSC) – Is a requirement under the OHSA of Ontario. A joint health and safety committee (JHSC) is a forum for bringing the internal responsibility system into practice. The committee consists of labour and management representatives who meet on a regular basis to deal with health and safety issues.

Load Haul Dump (LHD) – A vehicle used in an underground mining operation to facilitate the movement of material. Common nickname is a “Scoop”.

Mantle – A mining term referring to a device used to limit the size of material dumped into an ore pass. The mantle is heavy steel construction surrounded by concrete. A mantle has openings of an engineered size.

MEBS – Mine Exploration Borehole System. A system used to track drilled holes at a mine.

Ministry of Labour (MOL) – A provincial ministry within the province of Ontario that governs and regulates all labour matters within the province's jurisdiction. The mandate of the Ontario Ministry of Labour is to set, communicate and enforce workplace standards while encouraging greater workplace self-reliance.

MST Maintenance Schedule Task – Computer based system to plan, schedule and track required maintenance of specific equipment or devices.

Muck - Ore or rock that has been broken by blasting

OEM – Original Equipment Manufacturer.

Ore Body - A natural concentration of valuable material that can be extracted and sold at a profit.

Ore Pass - Vertical or inclined passage for the downward transfer of ore connecting a level with the hoisting shaft or a lower level.

Pendant – A device that facilitates the operation of a machine or remotely from the originating power source location.

ProdStat(s) – An internal company metric tabulating and tracking all movement of mined material underground.

Process Hazard Review -

Raise - A vertical or inclined underground working that has been excavated from the bottom upward.

Sand Fill - Hydraulic filling, stowing. The use of sand or plant tailings, conveyed underground by water to support cavities left by extraction of ore.

Seeping - To pass slowly through small openings or pores; ooze. To enter, depart, or become diffused gradually.

Spalling or Sloughing – The crumbling and falling away of material from the walls, face and roof in an excavation.

Sticky Muck – Refers to mined material that is wet and causes blockages/hang ups in ore passes.

Stope – An excavation in an underground mine from where ore is being or has been extracted.

Sub Level - A level or working horizon in a mine between main working levels.

United Steelworkers (USW) Local 6500 – an organization, affiliated with the United Steelworkers of America. USW 6500 represents employees, who are its members, in discussions about wages and conditions of work with management. Local 6500 consists’ of approximately 2600 members.

Ventilation Raise - a ventilation raise refers to a vertical or inclined excavation that leads from one level to another to provide a flow of air to the underground workings of a mine.

Wet / Dry Measurement – A calculation of the difference of two measurements taken from within a bin or ore pass. This calculation determines the height of the material within the bin minus the amount of impounded water.
Wet measurement is taken with a wooden ball that will float on the water in the bin or ore pass.
Dry measurement is taken with a steel ball that will sit on top of the solid material in the bin or ore pass.


2.2 Mine Location and Mine History -Frood / Stobie Complex

The Frood-Stobie Complex, comprised of the Frood and Stobie Mines, is located on Frood Road in Sudbury Ontario. The “Complex” was established over 100 Years ago and originally consisted of two mines: INCO's Frood Mine and the Mond Nickel Company's Mond Mine. Exploration activities had discovered the Mond ore body in 1884 while INCO's was discovered in 1899. Stobie Mine was opened in 1901 by INCO.

Later explorations discovered the ore bodies were shared. On January 1, 1929 the two companies amalgamated under the name INCO leaving two mines operating: Frood and Stobie.

The “Complex” had three non producing open pits on surface and is divided into four main underground work/production areas. These underground work areas are accessed and serviced by two main production shafts; (#7 & #9), and a ramp system. The ramp system extended from surface through Frood Mine into Stobie Mine Divisions A and B to 3600 Level. #7 Shaft is 4119 feet in depth and #9 Shaft is 2774 feet in depth.

The areas of the Complex are divided into the following areas:
1) Frood Mine - surface to 1400 Level
2) Stobie Mine Division 'A' – 1400 Level to 2600 Level
3) Stobie Mine Division 'B' – 2450 Level to 3600 Level
4) Stobie Logistics – 3750 Level to 3975 Level Loading Pocket (#7Shaft), 2200, 2400, 2840 and 2600 Loading Pocket (#9 Shaft)

#7 ore pass transferred Division B and some of Division A’s mined material to a crusher in the lower levels of the mine. #3715 ore pass was a converted ventilation raise that transfers Division B material to 2600 Level. The top of #3715 ore pass was on 2400 Level, with a dump location on 2450 Level and at the time of the double fatality bottomed on the 2600 Level. The top of the #7 ore pass was located on 2600 Level and the bottom on 3750 Level. Located below 3750 level was the crusher system that processes the material for delivery via the # 7 shaft to surface.


2.3 Mining Methods

The Stobie Complex was using three mining methods to extract ore from the underground mine. In use were Sub Level Cave, Vertical Retreat Mining and Upper Pillar Recovery. A fourth method Cut and Fill was not being used.

Of the three methods being used, two include backfilling with a sand mixture. This backfill was an integral part of the mining sequence and can be rock, sand (alluvial or mill tailings), gravel, hydraulic sand, or cemented hydraulic sand. Generally, the ore body was excavated in small sections, known as a stope , which were then filled completely, or in part, before the next stope is mined.


2.4 #7 Ore Pass

#7 ore pass was engineered and designed to be 11 ft. diameter, 362ft. long and contains 6 sections. Control Stations consisting of mantles (sizing devices) and chutes with crash gates were installed on 4 levels along the #7 ore pass (3000 Level, 3200 Level, 3300 Level and 3400 Level). The top of the #7 ore pass at 2600 Level was a dump location only with a mantle. The mantles allowed material to be dumped into the ore pass from the levels. The chutes with crash gates allowed material to be bypassed from levels as needed.

The ore pass section, from 2600 Level to 3000 Level, included a finger raise on 2600 Level and a control station on 3000 Level. The total storage capacity of this section including the finger and chute was 2600 tons within the original 388 ft. design. The #7 ore pass was unlined and the actual capacity could vary due to either spalling or narrowing of the opening caused by wet and “sticky muck” .

The control station located on 3000 Level was where the “uncontrolled run of muck” occurred.

2.5 Description of Accident Scene/Area

A site inspection was conducted by the United Steelworkers Local 6500 (USW) workers side of the Stobie Joint Health and Safety Committee (JHSC) at the 3000 Level #7 ore pass control station location.

The access to the #7 ore pass control station was on 3000 Level located off the main ramp. The control station work area was excavated 15ft. wide by (approx) 40ft. long by 15- 22 ft. high (ascending maximum height). This area was split into two sections divided by a cement wall and a narrow walkway.

In front of the wall were two 39 inch mantles (sizing devices) to dump material into #7 ore pass from the level by Load Haul Dump (LHD) equipment.

Workers and supervision were required to use a walkway approximately 3 foot wide by 7 foot high and 11 foot long, to visually observe the hydraulically controlled gate when bypassing material from the upper section of #7 ore pass (2600 Level to 3000 Level) to the lower section of #7 ore pass (3000 Level to 3200 Level). The “run of material” originated from material contained in the #7 ore pass above the 3000 Level. Both fatally injured employees were found in close proximity to the ore pass mantle at the walkway side access to the control gate, buried under the wet material.

Located within the #7 ore pass area were a variety of production support items, including:

• A small cut out containing an electrically controlled hydraulic operated power pack with the manual controls
• A remote control pendant that reached to where workers could observe the crash gate operation
• A blasting box to use when blasting ore pass hang ups
• The crash gate assembly complete with control cylinder.





3. Investigation of Accident

3.1 Accident Notification

The accident was first reported to Division A Supervisor, Luc St. Amant at approximately 10:13 P.M. on June 8th, 2011 by Roger Chartrand, miner. Tabatha Shaw, Plant Service Officer (PSO) and other onsite management were contacted at approximately 10:22 P.M. June 8th, 2011.

Shortly after, a call to 911 was initiated for emergency personnel (police, ambulance) to respond.

Offsite plant management and Local Mine Rescue were called starting at 10:30 P.M. June 8th, 2011 and a subsequent call to the Ministry of Labour (MOL) was made.

A call to Eric Delparte, temporary Stobie Mine Worker Representative was received at approximately 11:30 P.M.

USW Local 6500 Health and Safety Chairman Mike Bond was notified by Fred St. Jean, Acting Manager Safety at 12:28 A.M. June 9th that an accident at #7 ore pass 3000 Level had claimed the life of one employee and another was missing. Mike Bond then proceeded to call Rick Bertrand, President Local 6500, Nick Larochelle, Co-Chair Mines and Don Daily, Employee and Family Assistance Program.


3.2 Investigation Organization

Historically, a mine fatality or critical injury would be investigated jointly by company and union JHSC representatives. This procedure was successful in past investigations and the union representatives expected it would continue.

On Sunday, June 12th, Mike Bond USW Local 6500 Chair of Health and Safety held preliminary discussions with Vale management Jon Treen, General Manager Mines/Mill Ontario, and Kelly Strong, Vice President of Mines.

Team member names were exchanged at this point with the intention of performing a joint investigation into the double fatality at Stobie Mine. Over the next week, discussions were also held to set the ground work and frame work that the investigation would follow, including the final product.

Concerns respecting the format of the investigation were communicated by Mike Bond USW Local 6500 Chair of Health and Safety to Jon Treen, (General Manager Mines/Mill Ontario),and Kelly Strong(Vice President of mines) as to the direction of the proposed investigation.

The Union’s concern was that the investigation envisioned by the Company would not produce a full and impartial investigation. Specific concerns included the restrictions Vale was placing on the Investigation Team, the framework of the investigation, and the final outcome of the investigation.

After careful consideration, Mike Bond, USW Local 6500 Chair of Health and Safety, announced on June 23rd that a decision was made to conduct an independent investigation. The investigation of the double fatality was conducted under Section 9 (31) of the Occupational Health and Safety Act (the “Act”).

The reasons for the decision to conduct an independent investigation were outlined in a letter issued on June 23rd by Rick Bertrand, President of USW Local 6500 :

- The company, Vale, was demanding that the Investigation Team deviate from a defined and structured process that worked successfully in the past.
- The company, Vale, was creating boundaries that would limit the areas the Investigation Team would be able to investigate.
- The company, Vale, solely owns the investigation including:
a) Document control – no external communication
b) Direction and communication would solely be controlled by the Company
c) Information gathered would be strictly confidential
d) Participation in the investigation would be with limited rights

The deviation from the defined investigative process as proposed by Vale meant that Vale would solely own, lead, facilitate and manage the documentation relating to the investigation. As well the determination of accident causation, conclusions, and recommendations would be owned by Vale.

Given the restraints on the Union’s Investigation Team as proposed by Vale, USW Local 6500 determined that the rights of the families and its members would be better served with an independent investigation into the accident.

Section 9(31) of the Occupational Health and Safety Act (the “Act”) requires the workers side of Stobie Mine Joint Health and Safety Committee (JHSC) to report investigative findings to the Director of the Ministry of Labour and to the JHSC. T.


3.3 Investigation Process

The Local 6500 Investigation Team began its activities on July 4th, 2011 at 7:00 A.M. at the USW Steel Hall on Brady Street in Sudbury. After a briefing by Mike Bond, Local 6500 Health and Safety Chair, the team was selected from within the workers side of the Stobie Mine JHSC.

Aldo Cerilli was named as Lead Investigator on the workers side of the Stobie JHSC investigation. Under his direction, the team began collecting, reviewing and documenting the voluminous data from the Ministry of Labour requests. During the course of the investigation, the team further requested supporting documentation from the company to supplement their investigation.

Over the course of the investigation the team visited the accident site and other locations in the mine to take photographs and collect data and samples that would be key to the investigation.

The accident occurred on June 8th, 2011 and the MOL issued a stop work order immediately. The accident scene was not fully excavated or accessible for investigation until October 24th, 2011 when the MOL released the scene to the company. The stop work order issued on the ore pass was lifted on November 23, 2011.


3.4 Interviews

The Investigation Team conducted a total of 36 interviews. This included hourly mine employees, former employees and other outside individuals with firsthand knowledge of relevant facts.

Requests were sent to Fred St. Jean Manager of Safety asking to interview a total of 23 supervisors and management employees. Vale management personal Fred St. Jean or Peter Brady, Deputy General Counsel (Sustainability, Litigation & Regulatory Affairs) replied by email to each request stating that all supervisory and managerial employees had considered the request and that all had decided not to meet with the Union’s Investigation Team for questioning.

There was no direct eye witness to the incident. The information from the interviews was critical in helping to establishing a sequence of events leading up to the accident.


4. Description of Accident

Based upon employee interviews, radio transmission documentation , inspections of various levels of the mine and a site inspection of the accident scene, we believe the following events occurred the night of the June 8th, 2011 “run of muck” double fatality at the Stobie mine.

On the day of the fatalities, Jason Chenier reported to work early for a 2:30 p.m. production meeting. Jordon Fram reported for work at 6:00 p.m. his normal starting time.

At 6:00 p.m., on June 8th, 2011 during nightshift line up, Jason instructed Jordon to muck 2450 Level, #3722URM stope. Jordan traveled underground to pick up Load Haul Dump (LHD) #938 on 2400 Level. Jordon began mucking from #3722URM stope. At approximately 9:00 p.m. Jason reassigned Jordon to 3000 Level to muck into the #7 ore pass.

Jumbo Operator John Myles informed the Investigation Team that at approximately 9:25 p.m., he observed Jason at the #7 ore pass on 3200 Level, washing down material that was behind the crash gate. John Myles discussed with Jason the hazards associated about washing down material. Jason agreed and stopped. Jason left the 3200 Level crash gate partially open and proceeded to leave the area.

Jason then traveled up to 3000 Level #7 ore pass chute area to bypass material. He parked his jeep at the entrance to the crash gate access area. He walked into the crash gate area where he could operate the hydraulic crash gate pendant controls and observe the material he was attempting to bypass. Jason was in this area when the “run of muck” occurred.


At approximately 9:30 p.m. Jordon drove his LHD to #7 ore pass on 3000 Level and found Jason’s jeep blocking the access for dumping material into the ore pass. Jordan parked the LHD outside the access to the ore pass with a full bucket of material.

Shorty after Jordan entered #7 ore pass control station on 3000 Level to talk to Jason, a violent and massive “run of muck” occurred, fatally injuring both Jason and Jordan. It is estimated the double fatality occurred between 9:40 p.m. and 10.00 p.m. Roger Chartrand discovered the wet material from the ore pass that spilled over Jason’s jeep and into the main ramp at approx. 10:00 p.m.


5. Work Place Conditions/Work Practices
5.1 #3715 ore pass

#3715 ore pass was converted from the #3715 ventilation raise to transfer material from 2450 Level to 2600 Level. A portion of the ore pass continued from 2450 Level to 2400 Level and the top was capped on 2400 Level. The MOL requested documentation from the company with regards to the materials used to cap the raise. The company verbally stated no such documentation exists.

The #3715 ore pass had an irregular shape. From 2600 Level up approximately 50 feet the raise is 8 ft. in diameter. The remainder of the raise is 7ft. in diameter. This irregularity was due to a failure of the 8 ft. reamer bit used during construction of the original ventilation raise. To complete the ventilation raise a 7ft. reamer bit was used.

A dump wall (intended to prevent a piece of equipment and/or operators from entering an open hole condition) was installed on 2450 Level without a mantle. A mantle would have limited the size of material dumped into #3715 ore pass.

A worker would use LHD equipment to pick up wet mined material from the #3722 URM stope and dump it into the #3715 ore pass on 2450 Level.

The #3722 URM stope on 2450 Level was the last stope in this sequence on this level to be mined. The adjacent stopes have been mined out and filled with sandfill. The mining of #3722 URM stope began approximately May 2011.

The material mined from #3722URM stope, was acceptable at a 30% sandfill dilution. Interviews indicated that more sandfill was present than the 30% allowed by the geology report. This mix was recorded in the Supervisor Log Book as causing problems and being “sticky muck”.

In order to transfer this material from #3722 URM stope on 2450 Level to #3715 ore pass on 2450 Level, the LHD traveled through a large accumulation of water on the level, approximately 3ft. deep caused by plugged drain hole DH#3612. This depth allowed water to enter the bucket and subsequently dumped into the #3715 ore pass.


A plugged drain hole, DH#3283 on 2400 Level caused water to enter the top of #3715 ore pass. This introduced additional water into the already saturated material being dumped into the ore pass from 2450 Level.

The smaller size of the #3715 ore pass, the “sticky muck” and the lack of sizing devices (mantle) or designed chambers for secondary blasting allowed oversized material to be introduced. These conditions contributed to hang ups in the #3715 ore pass. These concerns were brought forth by LHD operators to their supervisors.

5.2 # 7 Ore Pass Design

The #7 ore pass is an unlined ore pass. In an unlined ore pass, the scouring effect enlarges the ore pass and creates an unstable opening at the bottom of the ore pass where material exits.

The #7 ore pass was an 11 ft. diameter pass driven with an Alimak raise climber on a near vertical 78 degree angle. The Vale engineered drawing showing the ore pass, including the finger and chute, is 388 ft long between section 2600 Level and 3000 Level. This section has approximately 2600 ton storage capacity. Approximately 10ft above 3000 Level the ore pass was enlarged 5ft left side, 5ft right side and 9ft on the hanging wall side for 40 ft. This widening increased the storage capacity in the ore pass.

Approximately halfway down the ore pass from 2600 Level there was a narrowing of the ore pass which contributed to hang ups. Management was aware of this condition and directed that more than one blast holed be drilled at this location. This narrowing was significant in contributing to hang ups in the # 7 ore pass.
It was calculated that the average LHD bucket of material would fill approximately 1.3 ft in the ore pass. Based on that calculation it would take approximately 298 buckets to fill the section from 2600 Level to 3000 Level.

The information relating to cushions above the crash gate was critical when workers were required to transfer material from one section of the pass to another. Such information would ensure a proper cushion was maintained to protect the crash gate, other infrastructure and the integrity of the ore pass in general.

The supervisor’s log had a section to document ore pass measurements and it was found that measurements recorded were inconsistent. Measurements taken and logged in the supervisors daily log book were in effect questionable due to the fact that there was a known ledge at approximately 71 ft. from the mantle on 2600 Level. The measuring device would “hang up” on this ledge as explained by Joey Santi, Superintendant Division A on June 10th, 2011.

Supervisors, or their designate, are required to measure and document the footage in the ore passes each shift in their daily supervisor log book. This measurement indicates the amount of material in the ore pass. Supervisors review these logs at the beginning of each shift.

The ore pass measurements are referred to as a wet measurement and a dry measurement . The reason for undertaking a wet and a dry measurement is to determine if there is accumulated or impounded water in the pass. Water in an ore pass can cause an uncontrolled run of material which is one of the most hazardous conditions in the underground workplace.

This hazardous condition requires immediate action including a plan of action (procedure), documentation and communication to other workers.

5.3 Crash Gate Operation
The transferring of material at #7 ore pass control station on 3000 Level was controlled by a steel crash gate. The crash gate was controlled by a hydraulic power pack outside of the crash gate area. The hydraulic power pack, which provided power to the gate controls, was located to the right side of the access drift in a small cutout into the wall. This hydraulic pack provided hydraulic pressure to open and close the crash gate. This action stopped and started the flow of material from above 3000 Level to levels below 3000 Level.

Two sets of controls operated the crash gate. One set of controls was located on the hydraulic power pack unit, but safe access was not provided due to the size of the cut out and the location of the power pack. The cut out was approximately three feet higher than the access drift area and the hydraulic pack was positioned sideways in the cut out with supplies blocking reasonable access to operate the controls.

Most significantly, from the controls on the hydraulic power pack, the worker cannot observe the material being bypassed. The worker would only know what function they are selecting (open or close). The worker could not visually observe the crash gate position from the power pack location, rather, in order to visually observe the crash gate and the transfer of material the worker would have to walk back and forth approximately 30 ft. between the ore pass and the hydraulic power pack.

The secondary set of controls (pendant type) was located in the crash gate area. These controls allowed a worker to operate the crash gate and observe the material being bypassed. However, by having these controls on the inside near the gate area, the worker was exposed to the hazards of flying debris, dust or uncontrolled runs of material.

The remote pendant is activated by a local/remote switch on the hydraulic power pack.

Engineered designs show pendant controls were to be mounted on the wall in the walkway to the gate area, approximately 4-5ft from end of the walkway. From interviews conducted, it was determined that the pendant controls were not mounted in this area. Of note, on 3200 Level, it was determined the pendant was not mounted to the wall as designed. The pendant was found lying on the concrete half wall separating the ore pass from the control area attached to the cable from hydraulic pack.

The controls on the remote pendant consisted of 3 buttons: a red e-stop button, open button, close button and one green light. The e-stop button needed to be pulled up to provide power to the hydraulic pack. Once the hydraulic pack was powered/energized, the open or close button could be pressed to move the crash gate in the desired direction. The gate only moved when a button was depressed. When the open/closed button was not depressed, the movement of the gate stopped.

The crash gate and power pack did not appear to be damaged from the “run of muck”, however, their condition before the “run of muck” was unknown. The investigators did not review and were not provided a daily use inspection checklist of the crash gate or power pack.

The crash gate on 3000 Level was found in a fully open position after the double fatality. Through interviews about hang ups and blasting, the team was informed that leaving the gate completely open was not a common practice. The team believes the gate was left in the fully open position to blast a hang up in the ore pass above.





5.4 Bypassing of Muck #7 Ore Pass

#7 ore pass was engineered and designed into 6 sections between 2600 Level to 3900 Level. In between the levels were 4 bypass crash gate control stations located at 3000 Level, 3200 Level, 3300 Level and 3400 Level. Each consisted of a mantle (sizing device) with two holes and a hydraulic operated crash gate (chute). The mantles are necessary to control the size of material the LHD dumps into an ore pass. These control stations were designed to allow for a LHD to dump material into the ore pass at different levels. The hydraulic crash gate was used to bypass material, sending it further down the #7 ore pass as required. The bypassing of material to the lower levels provided room to put material in at dump points located on levels above the transfer points.

To move muck at the different levels, the operator opened and closed the hydraulically controlled crash gate. When sufficient material had been transferred from behind the crash gate, the operator would then close the crash gate stopping the flow of material. A cushion above the crash gate was necessary to protect the crash gates from damage when material was dumped from above.

Through interviews the team learned that the Division B supervisor, in consultation with the Supervisor of Logistics, directed all movement of material in the #7 ore pass.

The Division B supervisor took measurements in the ore pass to determine the different levels of material in the various sections of the ore pass. If the supervisor believed water was entering the ore pass, a wet measurement would be taken along with the dry measurement. Both the wet and dry measurements, taken in the different sections of the #7 ore pass, were required to be recorded in the supervisors log book on a daily basis. These readings were necessary to keep an accurate account of how much material was in the ore pass system and how much material could be safely bypassed without removing the cushion required. After reviewing the daily shift log for the previous year, the investigators discovered that no wet measurements were recorded.

In comparison of shift and prodstat reports, it was determined the measurements recorded in the Supervisor’s Daily Log Books were inaccurate when compared to the amount of material in the ore pass. Some Supervisor’s Daily Log Books recorded the identical ore pass measurement for consecutive days, despite the fact that the prodstat reports indicated material was dumped into the ore pass during the same timeframe.


5.5 Water Management Drainage and Maintenance

The Stobie Complex on average pumped or managed approximately 3million gallons of water a day.

In mines like the Stobie Complex, with a history of significant water issues , it is crucial for safety and efficiency of operations to design, engineer, plan, develop and maintain a water management plan. Water drainage plans should at a minimum include written procedures on how to manage water flows, pumping systems, and methods of removing water from working areas of the mine.

Part of the Stobie water management plan was to have drain holes drilled on the various mine levels to direct, collect, and manage the flow of water throughout the mine. The management plan identified drain holes and their location.

It was found during the investigation that some drain holes were mislabeled and not documented showing the Stobie management plan was inadequate.







Drain holes were 6 in. to 8 in. or larger in diameter depending on the expected life, design use and future development in a specific area. These drain holes transferred water from one level down to the next, eventually directing the water to sumps or holding reservoirs at prescribed locations on mine levels. These sumps or reservoirs store the water prior to being pumped to surface. The drainage systems should be designed to manage all water used in the mining process that enters the mining area, including water from environmental seepage.

The drainage system design should include procedures for inspection and maintenance of the total drainage system to ensure the mine does not accumulate water in areas not intended to hold water. When a drain hole became plugged, unwanted water accumulated in areas that are not intended or designed for water storage and that water would then flow along the easiest path through the mine. These paths included unsealed blast holes, ramps, fractured ground, or down grade in haulage and roadways.

As witnessed in the physical conditions of the mine found after the June 8th, 2011 accident, this led to mining levels being flooded with water. This water migrated into several areas including areas adjacent to ore passes.

Part of the mining process includes using sandfill to fill voids created by mining activities. The process of using sandfill to fill voids requires the use of water. The water derived from this activity further stressed the drainage system.

Part of maintaining the drainage system required installing a drain tower at the top of each drain hole. The tower consisted of two parts 1) a sleeve that would sit inside the first 2-3 ft. of the drain hole to keep the collar of the hole stable and reduce the possibility of the hole collapsing and, 2) a strainer that would prevent obstructions from entering the hole. Common obstructions associated with drain holes include rock, sandfill, wood debris, plastic, mud, pieces of screen, and pieces of vent tube.

The 2400 Level, 2600 Level and 2800 Level drain holes were known to be plugged prior to June 8th, 2011. These holes were documented as plugged numerous times over the course of the year prior to the double fatality. Contractors had been hired to clean and open the drain holes on 2800 Level.

The Maintenance Scheduled Task (MST) system for water management was not active at the time of the fatalities. Since the fatalities the company has activated MST for drain holes.

Supervisors had little experience or training respecting the maintenance of the drainage system. Mine management is responsible to ensure that front line supervisors are trained and knowledgeable on water management.

5.6 Water Accumulation#3715 and #7 Ore Pass

#3715 Ore Pass

Water entered the top of the #3715 ore pass at 2400 Level because the drain holes on 2400 Level were plugged and prevented drainage. Water accumulations in this area were approximately 5 ft. above the top of the drain holes. This permitted water to accumulate and flow into the top of #3715 ore pass and travel down to the 2600 Level, mixing with the material being dumped from 2450 Level. Supervisors observed water at the dump point on 2450 Level running into the ore pass.

As a result of knowing that water was flowing into the ore pass, supervisor Jason Chenier, double barricaded the access to the draw point of #3715 on 2600 Level. Jason did this to restrict access to the ore pass.

Jason Chenier documented the double barricade in the supervisors log book on June 6th and June 7th, 2011. Joe Oliveria also documented the double barricade on June 7th and June 8th. (Both entries for the double barricade were not made in the safety section as required by law. Instead the double barricade was noted on the Mucking and Development status pages of the supervisors log book.)
Mine management reviewed these supervisor log books and Keith Birnie, Division B superintendent acknowledged the double barricade in an email to Jason Chenier on June 7th, 2011.

Water accumulations were also present on 2450 Level in the access to #3715 ore pass because of a plugged drain hole #DH3612. This created an area where LHD’s would have to travel through water levels approximately 3 ft. deep to dump material into #3715 ore pass.

On 2600 Level, high water accumulations were a direct result from drain hole DH#3432 being plugged. This allowed water to accumulate at the draw point for #3715 ore pass with levels reaching approximately 4 ft. and possibly higher.





Photo 6 Appendix BB


#7 Ore Pass

There were excessive water accumulations on 2600 Level at the bottom of #3715 ore pass due to drain hole #DH3432 being plugged. The LHD’s traveled through approximately 4 ft. of water at the draw point to pick up saturated material dumped from 2450 Level. The LHD operators did attempt to “skim” the bucket over the water to minimize the amount of water picked up in the buckets. Whatever water and saturated material that was picked up by the LHD bucket was dumped into #7 ore pass. This transfer of wet material was under the direction of mine management.

The 5 blast holes were drilled (#4407-#4411) into #7 ore pass on 2600 Level. These holes broke through into the ore pass. Water would flow into the ore pass through these holes. The holes had not been grouted or sealed as required.



On 2800 Level two plugged drain holes, DH #3257, #3257A caused water accumulations near #7 ore pass. Two weeks prior to the June 8th, 2011 double fatality, supervision reported these drain holes were plugged and needed to be cleared. A May 24th, 2011 notation in the supervisors log book documented the work needed and a local contractor was called in to assist in unplugging these holes. These drain holes on 2800 Level were not unplugged until after the double fatality.

On nightshift June 7th and again on dayshift June 8th 2011,drain hole DH #3372 on 2600 Level was unplugged. The water from this level flowed through this drain hole and down to 2800 Level sump where the drain holes DH #3257, #3257A were plugged.

The inflow of water from 2600 Level to the 2800 Level sump area raised the already high water level in this area and provided a path for additional water to enter blast holes BH#3906A, BH#3906B or BH#3906C into #7 ore pass. Interviewees stated the accumulated water level was so high in this area that it was observed running down the adjacent ramp.


5.7 Load Haul Dump (LHD) Bucket Design
The transfer of material from mining areas to an ore pass is done by the use LHD’s (Load Haul Dump). The LHD’s in use at the time of the fatalities were made by various manufacturers with buckets having designed holes to drain water when mucking wet material.

The company was not using the OEM (original equipment manufacturer) designed buckets that came with the LHD’s at time of purchase. The buckets in use were provided by a local supplier and had a different configuration of holes.
There was no defined process for keeping these LHD bucket drain holes clear. LHD operators advised the Investigation Team they did not have to plug drain holes in the current bucket design in use.

Older bucket holes were larger and were plugged with burlap and wooden wedges when cleaning sumps. This prevented drainage of water out of the bucket from the pickup point to the dump point. The plugging of holes was not common practice with the current non OEM buckets in use.

Wet material and water was transported from the draw points and dumped into ore passes at the direction of mine management. The shorter the tram distance with wet material the greater the possibility water would be introduced into ore passes. There was no defined standard to mix the wet material with dry material before dumping into the ore pass.

The material from #3722 URM stope was of high density that absorbed and retained water. The material being transported would act as a sponge due to its density.

The distance from #3715 ore pass on 2600 Level to the #7 ore pass was approximately 300 ft. This short distance, coupled with the small holes in the buckets, did not allow for water to adequately drain from the wet material. The #3715 ore pass had excessive accumulation of water present and had been double guardrailed prior to the fatalities.

Prodstats and Supervisor log books showed the double guardrail was removed and reinstalled to allow the transfer of material a minimum of three times in days prior to the accident. There was no documentation showing the hazard was corrected in the Supervisor log book prior to the double fatalities.

The mine LHD’s in use at the time of the accident did not have drain holes to adequately drain water from material being transferred to ore passes. There was no documentation provided by the company indicating a Process Hazard Review (PHR) was conducted on the new types of buckets in use at the time of the double fatality.


5.8 “Muck” Conditions

In Stobie mine on 2400 Level, 2450 Level, 2600 Level and 2800 Level water was able to combine with mined material at various points while being transferred to #7 ore pass. Material transferred to the #7 ore pass consisted of a mixture of mineralized material, sandfill and water. This material came from Divisions A and B areas of the mine.

Wet “muck” resulted when an excessive amount of water was absorbed in the material excavated in the mining process. The density of the mined material was a contributing factor as to how much water could be retained and the ability of the material to impound water.



Five samples of material that ran out of the #7 ore pass on 3000 Level were analysed. The results determined the sand and silt content was in excess of 50% on average and contained up to 13% moisture content 6 weeks after the double fatality.

On June 9th, a measurement was taken to determine how much material remained in #7 ore pass between 2600 Level and 3000 Level. This measurement taken from 2600 Level determined 217 ft. of material was left in the ore pass.

On August 4th, 2011 Vale management told the team a second measurement was taken from 2600 Level. This measurement showed 203ft. of material left in the ore pass.

A comparison of these two values demonstrates settlement of material of 14 ft. This settlement was from water seeping from the material in the ore pass.

Significant accumulations of water were observed on 2400 Level, 2450 Level, 2600 Level and 2800 Level on the night of the fatalities. These areas with water accumulations ultimately affected the mining material in #7 ore pass.

Some material being transferred to #7 ore pass came from 2450 Level, #3722UMR stope in Division B. This material taken from the stope was transferred and dumped into #3715 ore pass in order to allow material movement from 2450 Level to 2600 Level. The material was picked up on 2600 Level, transferred and dumped by LHD into #7 ore pass.

Other material dumped into #7 ore pass was transferred from various draw points by LHD on 2600 Level. This material was subject to water accumulations along 2600 Level.

Material mined from #3722URM stope on 2450 Level was the last in the sequence of stopes to be mined on this level. There was sandfill stopes on both sides of the #3722 stope. This allowed sandfill to mix with the ore.

The geology department determined the mixture 30% sandfill was an acceptable dilution ratio to proceed with mining of the stope. There were no controls in place to ensure the mixture did not exceed the 30% ratio.

Workers reported to supervisors this material as being “very sticky” and likely above the 30% ratio. It had also been reported as “sticky muck” in supervisor log books. The reports should have prompted mine management to order the engineering department to investigate. No such investigation was undertaken.

“Sticky muck” created issues and concerns downstream at several other areas along the “muck” circuit. Concerns included hang ups and blasting in #7 ore pass. The build up of sticky material is visible in the video taken after the double fatality. This “sticky muck” was also found on surface at conveyors and discharge chutes FS-3, FS-5.






5.9 Blasting Ore Passes

Blasting requires the use of various explosive products to breakup rock or other hard material. Careful handling procedures and practices enable workers to use explosives safely. There are several potential hazards from blasting including fly rock , the blast concussion , a sudden run of material in an ore pass, and the dust and harmful vapours created.

Blasting in ore passes, chutes or raises is referred to as secondary blasting. Secondary blasting was used to dislodge material in areas unsafe or inaccessible for equipment or workers.

Blasting hang ups is typically required at times when materials that are being transferred through an ore pass become stuck and block the movement of material in the ore pass.

Hang ups and blockages became considerably more frequent once wet muck and water was introduced to the ore pass system. The material in #3715 ore pass had been hanging up since May 18th, 2011. The #7 ore pass began having routine hang ups prior to the double fatality. This “sticky muck” became paste like when mixed with water and stuck to the sides of the ore passes, causing blockages. This “sticky muck” also contributed to water impounding in the ore passes, creating a further hazard. The “sticky muck” was a significant factor related to the hang ups in both ore passes, #7 and #3715.

Generally, blasting of hang ups at #3715 ore pass took place at the 2600 Level draw point. During interviews, while discussing blasting procedures, several workers stated they refused to blast #3715 ore pass at the bottom of the pass. The dangers associated with working around the open draw point, under hung material above the brow on 2600 Level at the ore pass was the major concern for refusing to blast. Workers had to expose themselves to the potential fall of material under the hang up to shove explosives into the ore pass using blasting poles. Workers had regularly voiced their concerns about the hazard; however no formal work refusals were put in by supervision on behalf of the workers.

Several workers and supervisors performed this unsafe task and blasting continued at #3715 ore pass, 2600 Level even though others had refused. Blasting was also undertaken on occasion at the top of the #3715 ore pass at the 2450 Level dumping location as it was considered “safer”. This type of blasting was not as effective in clearing a blockage so it was not used nearly as often.

Blasting hang ups at #7 ore pass 3000 Level crash gate area required workers attach explosives to blasting poles and open the crash gate enabling the placement of explosives up into the ore pass from the side of the crash gate. The crash gate was found in the fully open position after the double fatality, indicating it may have been opened for the possibility of blasting.


5.10 Ore Pass Blast Holes

Blast holes are holes drilled into an ore pass from a level above the blockage to help remove hung material that is restricting movement in the pass. This blockage is commonly called a “hang up” and is required to be documented in supervisor log book. This is described as “Pass is hung” in the supervisor log book.

Blast holes are required to be drilled according to the companies engineering specifications with both management and engineering approvals in place. These specifications direct drillers where to drill holes in order to intersect ore passes that have a hang up and are in need of blasting. The regulations require drilled blast holes to be recorded and documented on engineering mine level prints. The companies practice was to track drilled holes in MEBS. The blast holes were also required to be documented as an item needing correction (grouting and sealing) in Supervisor Log Books until the hole is plugged and grouted.

These company “drilled holes into ore pass” procedures are categorized as “critical” according to the procedure risk analysis evaluation worksheet. “Critical” designations require procedures to be reviewed annually. This required management, workers and JHSC to signoff that they reviewed the procedures. This system of reviewing critical procedures was not followed for the blast holes identified.

Previous hang up issues resulted in the #7 ore pass having a number of documented blast holes drilled into the ore pass from 2600 Level, 2800 Level and other areas over years. After the double fatality a video was taken of inside the #7 ore pass. Other holes were viewed in the video that are undocumented.

The Investigation Team found 2 inactive procedures for drilling breakthrough holes into an ore pass. There was no reference in these procedures for drilling holes two feet above (mine floor) grade as recommended in the Clifford Bastien coroners’ inquest.

There are 3 written procedures available for plugging drilled holes.

Four of the five procedures mentioned above were overdue for review. Procedure OPA37089 (drill breakthrough holes into ore pass) was the only active procedure as it was reviewed in October 2010. Management and workers that reviewed it in October 2010 could not be identified as signatures were not legible.

Additionally the procedures do not have any signoff signatures from the Superintendent (Mine Manager) of the mine. The failure to properly review and sign a review as completed, did not follow established company protocols.


2600 Level #7 Ore Pass Blast Holes

Near the dumping point into #7 ore pass on 2600 Level, a series of 5 holes were drilled in 2005. These holes identified as SB#4407 to SB#4411, all broke into the ore pass.
These holes were drilled to blast down a blockage/hang up that was stopping material from traveling in the #7 ore pass.

Of the five holes drilled only one hole SB#4407 was located after the double fatality. This hole was used to blast down blockage and then left open to be used in the future. Tests completed since June 8th, 2011 confirmed the hole SB#4407 was open into the ore pass, but the status of the remaining holes was unknown.

Over time, the sloughing of rock in the ore pass could have exposed the remaining blast holes to the ore pass. Lack of effective blast hole management resulted in unknown end states. Failure to grout and seal these blast holes would allow water to flow into the ore pass.


2800 Level #7 Ore Pass Blast Holes

In the year 2000, on 2800 Level near the 2800 Level sump, three holes were drilled into #7 ore pass. These holes were identified as SB#3906A, SB#3906B and SB#3906C. The purpose of these holes was to blast down a blockage in #7 ore pass. After the blockage was cleared the holes were left open.

The holes may have been plugged by sandfill that spilled in the area or roadbed material (slag) that may have gotten into the blast holes. If these blast holes were plugged with sandfill or roadbed material, it is uncertain if this material would have prevented water from flowing into the ore pass through the blast holes. Failure to effectively grout and seal these blast holes may have allowed water to flow into the ore pass.

One specific recommendation from the 1996 Clifford Bastien fatality Coroner’s Inquest recommended that; “all blast holes to be drilled 2 feet above roadway or above any possible water levels and grouted and sealed immediately after intended use”.

During the MOL follow up investigation into the 1995 Clifford Bastien fatality, the company stated they had initiated a procedure by which all holes that intersect an ore pass are to be drilled above grade. There is no reference in any procedures provided to the team that specifies drilling is to be above grade.





6. Safety Tools

6.1 SAF 079 - Injury/Incident/Unsafe Condition Recording and Investigation

Company policy PRO-SH-0008 Injury/incident/unsafe conditions states as follows:

“The purpose of this procedure is to establish a consistent means of recording investigating and recording all injuries/incidents/unsafe conditions information. It is also intended to ensure that all injuries/incidents/unsafe conditions are thoroughly investigated.”

“Investigation, analysis and follow up on recommendations from injuries/incidents/unsafe condition recording is an essential part of improving our ability to manage risks in the business successfully.”

“This procedure applies to all injuries/incidents/unsafe condition recording related to Ontario Operations activities, products and services”.

When an injury/incident/unsafe condition is reported, procedure requires the completion of the 079 form. The 079 reporting system was used for investigation of the reported injuries/incidents/unsafe conditions.

At the time of the double fatalities the generating/recording of the report was at the discretion of the supervisor. The completion of the report was at the discretion of the manager. Once initiated, supervisors reviewed the 079 report with workers during beginning of shift line ups to discuss injuries/incidents/unsafe conditions. It served as a communication media for hazards that were identified by the workers.

During the investigation interviews it was found that hazards identified by workers were not reported through the 079 system. Frequently workers were discouraged from reporting hazards; therefore many hazards were not communicated or addressed. The JHSC was excluded from generating a 079 report as well.

Had the 079 procedure been followed, a subsequent joint investigation would have included both a worker member and a management member of local JHSC committee. The common purpose of this joint investigation was to identify the basic cause and the remedies to prevent reoccurrence of the injuries/incidents/unsafe conditions. The workers side of the JHSC committee expressed to the Investigation Team that the company was not following the 079 procedure at the time of the double fatality.


6.2 General Safety and Hazard Alerts

General Safety

The Vale Ontario Operations General Safety Office (GSO) has a service level agreement with the mines and works as an independent group, functioning mostly in an advisory role. The level agreement states “To administer the Ontario Division Safety Programs in accordance with legal requirements, established company policies and results of risk assessments. This Agreement defines the mutual understanding and partnership on quality and timelines of services at Ontario Operation Mines. Furthermore, this Service Level Agreement defines the roles and responsibilities of the Customer (the company) and Supplier (GSO).”

The safety supervisor's duties are intended to be a resource to the plant. The safety supervisor has no direct line accountabilities in the Stobie mine complex and their presence underground or in surface work areas was minimal at the time of the double fatality.

One of the safety supervisor's functions was to communicate to other plants incidents and related hazards, internal and external. The Vale policy was to share with other mining companies their experiences with safety related issues and hazards.

The safety supervisor of a plant reports to the safety superintendent who then reports the safety manager. The GSO group is supposed to utilize Safety Reports as tools to communicate safety related issues to other safety personnel and to other plants.

Hazard Alerts

Hazard alerts are issued to serve as warnings to others, both internal and external, relating to hazards that have been recognized. These Hazard alerts also make other plants aware of serious situations that could affect their operations. The General Safety Office would assist to coordinate the development of Safety Reports in consultation with local JHSC members and technical experts as appropriate.

There was no Hazard Alert issued in relation to the water conditions found at the time of the double fatality. The Worker Representative requested a hazard alert to be issued and was denied by the company.

The GSO group was accountable at the time of the double fatality to notify proper personnel.


6.3 Guardrails and Signage

Workers use guardrails and signage to protect themselves and others against underground hazards in the workplace. There are specific requirements under the Mining Regulation 854 and the All Mines Standards (AMS) for the installation of guardrails.

AMS requires all installed guardrails to be secure, be clearly visible and have the hazard clearly identified on an attached sign.

There are two types of guardrails used underground: a single guardrail and a double guardrail. The spacing for a double guardrail would be minimum 1 ft. apart as a guideline.

Minimum requirements listed in the AMS for guardrails, signs and the material used to erect guardrails include the following:

• No persons may remove a guardrail without authorization to do so except for the purpose of performing authorized work.
• No persons may pass through a double guardrail without the ac

February 24, 2012


Release of the Investigation Report on the double Fatality at Stobie Mine


Sisters and Brothers,

After a long and challenging investigation on the double fatality at Stobie Mine that killed Jordan Fram and Jason Chenier on June 8th, 2011, Local 6500 will be having special meetings at the Union Hall.

The Executive will inform our members the cause of death in the double fatalities and discuss the recommendations that Local 6500 will be proposing to improve the safety and working conditions at Vale’s Stobie Mine, also for all other mines in the Sudbury basin and at all underground mines throughout Canada.

The special meetings will be held on Wednesday, February 29th, 2012 at 2:30 pm and 7:30 pm. For those members who are unable to attend the meetings, you can view the investigation report on our website – www.uswlocal6500.ca


In Solidarity,



Rick Bertrand Mike Bond, Chair
President, Local 6500 Health, Safety & Environment
United Steelworkers Committee, USW Local 6500

Labour Board Ruling Vindicates Steelworkers In Case of Fired Employees

SUDBURY, 24 February, 2012 – Mining giant Vale engaged in “patently unreasonable” conduct and violated provincial labour law by firing nine Sudbury workers without recourse, the Ontario Labour Relations Board has ruled.

“This ruling is another concrete example of Vale’s blatant disregard for workers’ rights, for our laws and for our country’s labour relations traditions and culture,” said United Steelworkers International President Leo Gerard.

“This is a major victory for our union, for the working families who have been adversely affected by Vale’s unlawful conduct, and for unionized workers throughout the province,” said USW Local 6500 President Rick Bertrand.

“It is shameful that the affected families have suffered in limbo for more than two years due to Vale’s illegal decision to deny workers their right to independent arbitration,” Bertrand said.

The OLRB ruled Friday that Vale violated the Ontario Labour Relations Act by maintaining a “patently unreasonable” position with regard to nine workers fired by the company during a yearlong strike in Sudbury in 2009-10. Two of the fired workers – Patrick Veinot and Jason Patterson – also were elected officers of the local union.

Vale broke the law by not “making every reasonable effort to make a collective agreement” during negotiations, as required by legislation, the labour board stated in its 29-page ruling, which made repeated references to “troubling” behaviour by Vale.

The labour board agreed with the Steelworkers that the fired workers must have recourse to the long-established right and tradition of third-party, just-cause arbitration.

“The Ontario Labour Relations Board has upheld the reasonable position that our union had put forward since March 2010,” said Wayne Fraser, the Steelworkers’ director for Ontario and Atlantic Canada who was the union’s chief negotiator during bargaining with Vale.

A memorial mass will be held Friday at 10 a.m. at Christ the King Church for Stephen Perry, who was killed Sunday afternoon on the job at Coleman Mine in Levack.

Perry was from Corner Brook, Nfld., but had worked with Inco and Vale for 16 years. Vale vice-president Kelly Strong called Perry a skilled and experienced miner who was respected by his colleagues.

Family in Newfoundland said he was a kind and giving man, who would do anything to help someone in need.

Perry is survived by a daughter and several siblings.

Vale suspended operations at all five Sudbury mines after Perry was killed working on a piece of machinery to load blasting equipment to open up the 4,215-foot heading off the Coleman shaft in the main ore body.

The Ontario Ministry of Labour and Greater Sudbury Police Service have been at the site beginning their investigations. Vale and the union representing Perry, United Steelworkers Local 6500, will also conduct investigations.

Whether those latter investigations will be done jointly or individually isn’t known yet. Local 6500 president Rick Bertrand said Monday it was too soon to decide.

Vale spokeswoman Angie Robson said Tuesday the company and the union had discussions and “(we) remain hopeful we can conduct a joint investigation with them.”

By: Mark Gentili - Sudbury Northern Life
Nearly 50 members of Stephen Perry's family will be in Sudbury for the fallen Vale worker's funeral, Feb. 3.

The 47-year-old development miner died early Sunday afternoon after rock came loose from the face of a development drift at the 4,215-foot level of the Coleman Mine in Levack. Perry was working alone in the drift, using a piece of equipment called an “Anfo loader” to load explosives into the face of the rock.

He was found and brought to the surface, where he was pronounced dead by medical authorities.

Vale isn't sure what caused rock to become displaced, but has said the explosives with which Perry was working were not a factor in the accident.

Perry leaves behind a 19-year-old daughter, who lives in Chelmsford, as well as a very close extended family that includes 13 siblings.

His eldest sister, Bernice Pieda of Corner Brook, Newfoundland, said Perry's daughter meant the world to him.

Vale employees sent home for 'safety pause' in wake of Sunday's fatal Coleman mine accident

For the second time in the past few months, Sudbury miners are home today for what's known as a "safety pause."

Vale stopped work at its five mines following the death of a worker at Coleman Mine in Levack over the weekend.

Lloyd Harris, who works at Creighton Mine, said he was told to “go home and the supervisor will call you ... I don't know, [i] guess it's time to go home and reflect."

Harris has been a miner for four decades and said fatal accidents always weigh heavily on people. He said he believes worker morale was already low at Vale — and this fatal accident just makes it worse.

"[It] just adds to … the frustrations that the guys are going through,” he said.

Homer Seguin, a former union leader and a champion of worker safety, said the three fatalities in Sudbury in the past year feel like a step backwards.

"It's like going back to the old days when we were having somebody killed every month,’ he recalled.

Xstrata, another local mining company, also had a work stoppage in November 2011, after a series of minor injuries at its two Sudbury mines.

United Steelworkers Local 6500 is "dotting the I's and crossing the T's" on its report into its investigation into the deaths of two Stobie miners June 8, 2011, and will share its findings soon with members and the public.

Local 6500 president Rick Bertrand said the union is making sure its report is thorough so that "when we walk away, we can say we're pleased with the investigation (and) we've done everything we can."

Vale Ltd. released the findings of its investigation Tuesday at a news conference. That report didn't pinpoint exactly how Jason Chenier, 35, and Jordan Fram, 26, were killed about 9:45 p.m., while working at the 3,000-foot level near the No. 7 ore pass at Stobie.

Kelly Strong, vice-president of mining and milling for Vale's North Atlantic operations, said six factors contributed to the men's deaths-- water manage-m ent, ore mixing, ore pass management, operational controls, roles and responsibilities, and training and awareness.

Vale's investigation team made more than 30 recommendations and established an action plan to ensure such fatalities don't occur again. Many of the recommendations have already been implemented, said Strong.

Bertrand wouldn't say what will happen with the union investigation team's findings after they are released.

But Local 6500's report will be presented to members and the public.

The union's 2,600 production and maintenance workers were deeply shaken by the deaths, whether they knew Chenier and Fram personally or not.

TORONTO, January 27, 2012 — Brazilian multinational Vale is a worthy recipient of the 2012 Public Eye People's Choice Award for the world's worst company, the United Steelworkers (USW) says. The award was presented today in Davos, Switzerland, where corporate chieftains and political leaders are meeting for the annual World Economic Forum.

Nobel economics laureate Joseph E Stiglitz presented the award on behalf of its organizers — the Berne Declaration and Greenpeace Switzerland.

"This vote demonstrates the increasing global awareness of Vale's terrible record..."



Stiglitz also called on multinational corporations to go "beyond the minimum required by the law to protect the environment, to treat workers with decency and fairness, not to exploit all the advantages that asymmetries in bargaining might afford."

"Vale certainly is a deserving recipient of this international recognition," said Ken Neumann, United Steelworkers National Director for Canada.

"In the short time since it ventured into Canada in 2006 with its takeover of Inco Ltd., Vale has provoked unprecedented labour disputes, attacked working standards, worsened labour relations, slashed jobs, and announced harmful plant closures," Neumann said.

"What's more, Vale's record in other parts of the world is even worse," he added.

More than 88,000 people around the world voted on the 2012 Public Eye award. The award competition is organized by the Berne Declaration and Greenpeace Switzerland to choose the worst case of contempt for the environment and human rights.

Class action involves 8,000 Port Colborne residents

The class action lawsuit against Inco by 8,000 Port Colborne residents could be going to the top court in the country.
Application for appeal has been filed to the Supreme Court of Canada by the plaintiffs in the case. In 1984, the nearly 8,000 residents were awarded a total of $36 million for damages as a result of nickel contamination from the old Inco refinery on Port Colborne’s east side. Last fall the Ontario Court of Appeals overturned the decision, taking Inco (now Vale) off the hook for the $36 million.

“Ultimately, we have no way of knowing (if the case will be heard). It’s entirely up to the court,” said Eric Gillespie, lawyer for the plaintiffs.

Today, January 26th at 2:30 we will be having our Grand Opening for our new state or the art union hall/ conference center. Light refreshment and snacks will be served. C'mon out and see your new building!!!