1. Grader and Pick up Incident June 30 th, 2011

2. Incident Overview 2  On September 20 th,2011 at approximately 2:30am Dan had just finished filling 3 of his 4 car train when the chute became hung up. He began to climb the wooden ladder up to the chute.  As he was stepping off the ladder to access the chute platform, the ladder kicked out and Dan fell 8 feet to the ground, landing on his back on top of the ladder.  The ladder had not been properly secured in place  Dan did not loose consciousness but suffered a separated shoulder and compression fracture of vertebra L-1.

3. How many workers died from falls in Ontario construction in 2008 according to the Construction Safety Authority of Ontario 3 CSAO 2008 Statistics

4. 10 4 CSAO 2008 Statistics

5. Incident Area 12 Level T026 Chute 5

6. Dan’s position after fall (re-enactment) 6

7. Root Cause 7  Ladder to chute platform not securely fastened - Failure to secure /make safe (ladder was not secured properly to ensure it could not fall, ladder did not extend 1 meter above landing it only extended 0.6 meters above landing) - Improper Placement (ladder was not placed in the proper location. Base of ladder was placed on wet planking, and did not have a stop block to prevent the ladder from kicking out.) -Training done, failed to transfer knowledge (both workers and supervision failed to recognize the risk of not having the ladder secured.) -Inadequate assessment of needs and risks (risk of not securing ladder was not recognized. The chute design does not have the ladder in the proper location.)

8. Root Cause continued 8  Ladder to chute platform not securely fastened - Lack of procedure for the task (There are no company procedures dealing with the installation and securing of ladders for chutes. It has become an accepted practice not to secure ladders at chutes.) - Inadequate enforcement of the rules ( Legislative requirements of properly securing ladders and having ladders extend 1 meter above the landing were not followed.

9. Root Cause 9  Previous ladder incident at T026 chute not properly reported and investigated. - Failure to warn (Worker failed to properly report severity of falling 8 feet off the T026 ladder the previous week.) - Inadequate physical/mental capability (Worker used poor judgement in not properly reporting incident, and did not realize the potential consequence or severity of incident. - Inadequate leadership/supervision (Supervision and management failed to recognize risk and failed to follow up on incident’s root cause and take actions to prevent a reoccurrence.)

10. Recommendations 10  Audit all ladders in the underground to ensure they are properly secured.  A Team Up of all chutes ladders to be completed.  All ladders to be properly secured and extend 1 meter above the landings at all underground chutes.  Develop method of securing ladders so they can be removed for chute clean up and then easily reinstalled and secured.  Review engineering design and construction of chutes including all existing chutes, specifically ladder location and platform accessibility.

11. Recommendations (cont.) 11  Chute training manual and chute pulling procedure to include ladder installations and how the ladders are to be secured. These to be reviewed with all underground crews.  Add ladder inspection for chutes and sub level access to the supervisory weekly audits.  A chute pre-op inspection card to be developed and used daily by chute crews.