The jury produced 15 recommendations after all-day deliberations late Wednesday, including urging WorkSafe BC to hire more agricultural inspectors and to educate workers on the risks of operating in confined spaces.
“Our family is tremendously happy right now,” said Tracey Phan, the daughter of brain-damaged worker Michael Phan. "After four years, we can get a good night’s rest."
The workers were killed on Sept. 5, 2008 when toxic gas unexpectedly spewed from a brown-water pipe they had forcefully unclogged in an enclosed pump shed.
Hydrogen sulfide had built up in the pipe while it was plugged, and its release killed Ut Tran, Han Pham and Jimmy Chan, who were trapped inside the confined space of the shed. Two more workers suffered severe neurological injuries.
Five jury members sifted through a slew of contradictory testimony and anecdotes about missed opportunities from about 30 witnesses during the seven-day inquest.
But the common theme that emerged was of an apparent complete disregard for the safety of workers at the farm's composting facility.
The jury was tasked with making recommendations that will prevent similar tragedies in the future, making suggestions to B.C.'s environment minister, the BC Ambulance Service and WorkSafe BC.
"There's no question in my mind that there are important recommendations here that will change and save lives in the fields and farms of British Columbia," said Jim Sinclair, who heads the B.C. Federation of Labour.
He called on WorkSafe BC to implement the recommendations as quickly as possible.
The jury's recommendation for safety training is key because at present such training is only done on a volunteer basis.
The members asked the B.C. Environment Ministry to require that a registered engineer always “supervise and approve” the design and construction of all aspects of composting facilities, and change regulations so facilities actively aerate their brown-water tanks.
They also want all employers to send yearly reports declaring they have fulfilled their safety obligations to WorkSafe BC.
More random inspection visits were also recommended.
B.C. NDP labour critic Raj Chouhan said there's been instances where the government has received recommendations after a farm tragedy but not carried them all out.
He cited an accident in March 2007 when three farm workers were killed roadside.
"I hope the government will not repeat the same mistake," he said of the unfulfilled recommendations. "In this case I sincerely hope they will act upon it very quickly."
On the day of the lethal accident, the men had worked for hours to free a blockage in a water pipe used for the production of the composting facility.
They sawed off rusty bolts from the pipe and used a screwdriver to pry out a mixture of straw and manure.
The partial release of the blockage also released gas that had been forming in the pipe for days.
One of the workers complained of the bad smell and then collapsed, while the others who tried to help him either died or were injured.
The jury heard that the minutes following the toxic leak on the farm were completely confusing, as no one knew why the men had collapsed.
The first ambulance attendants on the scene refused to go inside the hut where the fatalities occurred. Just months before, the men had taken training on confined spaces and lack of oxygen after two ambulance attendants died in such a scenario in 2006.
The chief investigator of the accident with WorkSafe BC told the inquiry that it was fortunate more people in the area hadn't been killed.
Mohinder Bhatti said that had the wind been blowing in the right direction and the men freed even more of the clogged pipe, hydrogen sulfide could have killed dozens working and living in the area.
The jury heard the workers could only speak Vietnamese and most couldn't read or write in their own language. But it was only after the accident that WorkSafe BC issued safety pamphlets for farm workers in numerous other languages.