The only health or safety initiative at the mushroom farm where three workers died from inhaling toxic fumes was an informal reminder to "be careful," according to a WorkSafe BC report on the incident.
Two more workers were left with severe brain damage after the incident at the A-1 Mushroom Substratum Ltd. composting facility in Langley on Sept. 5, 2008, but workplace investigators say no one would have been hurt if proper safety procedures had been followed.
"This was a tragic loss of life and would have been entirely preventable had the employer complied with occupational health and safety laws and regulations," Jeff Dolan, director of investigations for WorkSafe BC said in a press release Monday.
The report found that the dead and injured workers were exposed to hazardous gases while working in a confined space without taking the necessary safety precautions.
The tragedy was sparked when two workers and a supervisor tried to clear a blocked pipe inside a pump shed. When they separated the pipe, it released toxic gases -- most likely hydrogen sulfide and carbon dioxide.
The worker closest to the pipe collapsed within seconds and quickly died. The second worker survived the incident, but suffered severe brain damage.
The supervisor left the barn to call for help after both workers lost consciousness, but three more workers overheard the commotion and ran into the shed to save their colleagues. Two of them died, while the third was left with serious brain damage.
An animated reenactment of the tragedy is available here.
The facility's construction played a big role in what happed that day, according to WorkSafe BC.
"Going back to 2004, the facility was designed, built, and operated with inherent flaws that created the conditions for hazardous gasses to build up and for the blockages in the pipes to develop," the report reads.
That problem was compounded by the fact that the farm had no program to deal with hazards in confined spaces like the pump shed, and no real policies to ensure worker safety in general.
According to the report, the farm had problems in the past, and neighbours had complained to the township about the smell and air quality around the facility.
The township got a court order to temporarily shut down the farm in 2007 because of bylaw infractions, and was in the middle of a second legal action at the time of the incident.
The Greater Vancouver Regional District was also considering action against the farm because of unauthorized discharge of contaminants into the air.
WorkSafe BC had previously received four complaints about the farm concerning the air quality and workers' safety. The report says that the worker safety board "missed opportunities" to enforce safety regulations at the farm.
Last week, A-1, mushroom farm H.V. Truong Ltd., and three owners of the companies were fined a total of $350,000 for their roles in the devastating episode. None of those convicted will face any jail time, and were charged under the Workers Compensation Act and Occupational Health and Safety Regulations rather than the Criminal Code.
A-1 is now bankrupt and unable to pay its $200,000 fine.
The BC Federation of Labour is calling for a separate coroner's inquest to determine exactly what went wrong.
