After hearing from nine witnesses, the five-person jury examining the 2019 workplace death of James Martin came back with two recommendations.
The first is that all employees involved in bridge construction and maintenance be trained "in all aspects of health and safety pertaining to" that specific type of work.
Further to that, jurors said an "accountability system" should be put in place for those who don't comply.
The jury also recommended that daily morning inspections be done at work sites to identify hazards and make sure all safety measures are in place. They suggested a checklist to ensure compliance.
The presiding coroner, Emily Caissy, added several recommendations of her own.
She said the Department of Transportation and Infrastructure should develop an awareness campaign for workplaces. She suggested a "see-something-say-something" approach for all workers.
She also suggested the department clearly specify who is responsible for various tasks on a project. She said proper follow-up should be conducted to ensure compliance.
Caissy also said DTI's outdated bridge-building manual should be updated and employees should be properly trained on its contents.
She said all bridge-building employees, regardless of whether they're casual or full-time, should be "certified and competent" in working at heights.
Before dismissing them, Caissy told jurors that all of the recommendations will be passed on to the Department of Transportation and Infrastructure.
Martin's widow, Rayma, and daughter, Holly Jones, say they are hopeful the recommendations, together with the changes that have already been made since Martin's death, will help prevent similar deaths in future.
Those changes addressed something the family criticized after the Department of Transportation was fined $125,000 in the case.
The family said it was simply one government department writing a cheque to another government department.
But changes to the regulations now give judges the discretion to direct fines be paid elsewhere in order to support occupational health and safety education or research, or similar initiatives by non-profit organizations.
"Hopefully these recommendations will be taken seriously and that they will be adopted and put into policies and legislation, so that we can hopefully prevent accidental workplace deaths from occurring for other families," said Jones on Wednesday at the conclusion of the inquest.
Jones said she isn't sure any one recommendation would have prevented her father's death. She said it only takes one seemingly small thing to be overlooked to have a huge impact "and change the course of your family."
Testimony from 9 witnesses
Over two days, the inquest heard from nine witnesses, including Martin's co-workers and supervisors. It also heard from the WorkSafeNB investigator who examined the incident.
They heard that 64-year-old Martin was part of the bridge crew with the Department of Transportation and Infrastructure's Zone 5 in the Woodstock area. They had already spent a few weeks at the site, working on a new bridge.
At the end of the day on Aug. 26, 2019, they were putting up a 2x6 wooden railing along both sides of the Bedell Bridge. They had forgotten the bolts, so they zip-tied and wired several sections of lumber to the bridge's metal posts.
It was supposed to be a temporary measure until they could return the next day with the right bolts and secure the railings properly.
But they forgot to take the bolts the next day.
And although several witnesses said the bolts were loaded into the truck on Aug. 28, they were never used to secure the railings.
At about 1:15 p.m. that day, Martin sat on the railing. It gave way and he toppled over backward, falling 3.35 metres to the rocks below.
He died early the next morning at the Saint John Regional Hospital, after being transferred from the Waterville hospital.
Barrier not up to standards
On Wednesday, the WorkSafeNB investigator assigned to the case returned to the stand to discuss his conclusions.
Michel Cyr testified on the first day of the inquest, but presiding coroner Emily Caissy asked that he wait to discuss his conclusions.
Although much of the testimony centred around the missing bolts, Cyr said even with bolts, the wooden barrier would not have met the standards in the regulations.
Cyr said such safety barriers would have had to have three rails, not just one.
He also specified that the zip-tied and wired railing was installed two days before Martin's death, not the day before as several of the previous witnesses described. That means the temporary measures were in place for an extra full day, rather than just one morning.
Also on Wednesday, the supervisor of the bridge crew testified that although there was talk of implementing "safe work plans" for every project, it was not yet mandatory at the time of Martin's death.
It soon became mandatory, said Stephen Lappage.
In fact, once Martin's crew returned to work six weeks after the accident at a different location, there was a plan in place that everyone had to be aware of and sign off on.
Lappage, who retired three months after Martin's death, said he worked alongside the rest of the crew. He was there when the rail was zip-tied and wired and knew the bolts were missing.
"We all talked about them," he told the inquest. "The length of them, the size of them and how many we needed."
He said they were completely forgotten for a full day, and on the third day, he said everyone got to work and "just totally forgot about them."
Lappage said it would have been his job to inspect the site and make sure everything complied with the rules. He said he didn't inspect the rail the morning of Martin's fall.
"Never thought of it. It just totally blows my mind that I didn't," he said.
"In about 15 minutes, we could have had all of the bolts in."
Lappage had actually returned to the shop to complete some paperwork and return some extra supplies at the time Martin fell off the bridge.
When he returned to the site after being told about the fall, Lappage said Martin was being restrained and kept asking for help from Eric.
That's not unusual with a head injury, said Opalee Budd, a paramedic who responded to the scene.
By the time she arrived, Martin was half-seated on the rocks, surrounded by his co-workers. She said he was agitated and wanted to stand up.
She said he had a large laceration to the right temporal area and had abrasions on his back. She said he continued to be "quite combative" and tried to take the neck brace off.
Budd said Martin was experiencing short-term memory loss, his pupils were "sluggish to respond," his blood pressure was rising, and he moved his arms around a lot.
She said it would have been better to take him to the emergency department in Fredericton, but because of how combative he was, the decision was made to taken him to the closest hospital in Waterville.
Transferred to Saint John hospital
He was eventually transported to the Saint John Regional Hospital.
Michael Johnston, who is the acting deputy chief coroner, was the coroner on call that night in the Saint John area.
He said a CT scan revealed bleeding in "different layers of the brain." The prognosis was so poor, Johnston said treatment switched from life-saving measures to providing comfort.
Martin was pronounced dead at 1:29 a.m. on Aug. 29.
Cyr said WorkSafeNB issued a stop-work order on the day of the accident.
In fact, Martin's co-workers never returned to complete the Bedell Bridge, said Lappage.
For six weeks, they stayed in the shop and when they were allowed to go back to work, they went to a project in Hartland.
When his testimony was complete, Martin's daughter, Holly Jones, had a question for Lappage. She wanted to know whether there was a safety plan in place for the Bedell Bridge.
Lappage said "there might have been" but he didn't remember filling it out.
Ian Nicholson, the superintendent of bridges in the Woodstock area, said there wasn't a work safe plan in place at the time.
He said it would have been up to him to do it and get it signed by everyone on the crew.
When he was asked why it wasn't done, he said because it was a new process and "plainly, I just didn't think of it. I just forgot."
Although such plans are mandatory now, Nicholson said he wasn't aware of it being mandatory at the time of Martin's death.
On Wednesday, the inquest also heard a tape-recorded interview taken within days of the incident with David Denny, who was part of the work crew on Aug. 28.
He said the group was on a break trying to stay cool in the heat, when Martin sat on the rail.
Denny said Martin adjusted himself and when he sat back down, the rail collapsed and he fell over backwards.
He said Martin sat on the part of the rail that was spliced together.
Changes already made to legislation
When Cyr returned to the stand on Wednesday, he said the regulations are very clear about safety barriers during construction above a certain height. He said they require a top and middle rail and a toe board. Although the regulations don't stipulate the mechanism by which the railings are attached, it does say that it has to withstand a weight of 200 pounds.
The Department of Transportation and Infrastructure was charged with three violations of workplace safety regulations.
The department was fined $125,000 in July 2020 after pleading guilty to one of the charges by failing to provide safe guardrails that would have prevented Martin from falling to his death.
After the court case, there was some criticism of one government department paying a fine to another government department, said Cyr.
Since then, changes were made to the province's Occupational Health and Safety Act, giving judges the discretion to make the fines payable elsewhere in order to support occupational health and safety education or research, or similar initiatives by non-profit organizations.