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Kamloops man's workplace death could have been avoided if there was proper supervision, training: report

Many errors caused death

The fatal workplace accident that claimed the life of Brendan Stokes could have been prevented, according to WorkSafeBC.

A redacted incident investigation report shows that a sequence of events and errors led to the then-19-year-old's death.

On June 29, 2018, Stokes and another employee of Kamloops Tirecraft were dispatched to complete repairs on a wheeled loader that had a flat tire; it had been parked in an industrial yard in Dallas. With the tire removed, Stokes went under the wheel hub and axle assembly to clean the hub. The axle slipped off the jack and the loader fell on him.

WorkSafeBC investigators found that the saddle of the jack was slightly "crowned" and had a cross indentation (the manufacturer's instructions says the saddle should be flat). There was also some dirt on the bottle of the axle housing of the loader. These scenarios would have reduced the friction between the two metal surfaces, the report says. 

The jack's manufacturing instructions also say that the jack is for elevating equipment only, and not for support.

"Personnel must not go under the equipment when it is elevated solely by the jack," reads the document.

Another contributing factor to the loader slipping was that there was a depression in the ground under the steel crib kit. The report notes a jack plate should have been used to help level the surface. A jack plate was found on the flatbed service truck at the time of the fatal incident. 

The WorkSafeBC report says Kamloops Tirecraft had not created any written safe work procedures for this type of tire repair. It also did not have manufacturer's instructions for the steel crib kit, jack or cribbing blocks for employees to review.

Besides the documented orientation Stokes received on his first day of work, no other documentation of training was provided by Kamloops Tirecraft, according to the report.

"Kamloops Tire failed to provide its workers with adequate training and instructions for OTR (off-the-road) tire service work," the report says. "Not providing young and new worker training to the workers increased the risk of unsafe work practices and, therefore, increased the risk of injury."

Since the the incident, Kamloops Tirecraft has developed a 17-step OTR tire service procedure manual. Further training on repair procedures has also been provided to all tire technicians. 

On April 2, 2020, WorkSafeBC fined the local company $8,400 for the workplace fatality. The fine sparked an online petition, calling for higher penalties. To date, more than 14,500 people have signed the petition.

Stokes' mom Kara called the fine "a smack in the face."

Redacted report by Teresa Verenca on Scribd



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