The jury for the inquest into Troy Bourque's death at Devon Lumber in Fredericton, N.B., has determined his death was accidental. 

The jury put forward three recommendations to prevent similar deaths and Michael Johnston, the presiding coroner, added one of his own.

On Monday, the jury heard that Bourque died on Oct. 10, 2019, after trying to fix a cover on a moving conveyor belt. Spencer Gill, a coworker, said the metal cover became stuck in the moving belt and crushed Bourque against the bottom of a catwalk.

The jury recommended:

• Devon Lumber conduct weekly safety meetings and on-going training with monthly work site inspections.
• Standard operating procedure manuals are developed, including protocol for an accident, mechanical failure or maintenance.
• The location of safety equipment and emergency stops for machinery are reviewed regularly with employees, as well as the manuals.

                                                Bourque died on the job after being crushed by a piece of equipment. (Submitted by WorkSafeNB)

Johnston recommended that WorkSafeNB continue its focus on lockout, tag-out procedures while inspecting sawmill operations. This refers to a procedure where a machine is drained of energy and locked so it can't be operated.

Mill president asked about safety

On Monday, Harry Gill, the president of Devon Lumber, said the fix Bourque had attempted should have been done during a lockout. Gill added that the issue hadn't been reported to maintenance before Bourque tried to fix it. 

On Monday, Gill was asked if safety talks with staff had changed after the accident. He said they hadn't changed much and mostly happen one-on-one between workers and other staff such as himself. 

The president of Devon Lumber said his company has spent thousands on physical safety improvements since this accident. (Joe McDonald/CBC)

"A lot of the guys are senior guys. So new guys, we're very careful. We only place new guys in areas that are very, you know, not much moving equipment until we're confident with them," Gill said. 

Bourque had worked at Devon for 29 years at the time of his death. 

Gill said his company has spent thousands in physical safety improvements around the mill since 2019. 

"It really bothered me. It's been tough for me and the family," he said of the incident. His family has run the company since it was created in 1942. 

On Tuesday, Michel Cyr, acting assistant director of investigations at WorkSafeNB, said the agency's investigation concluded with no charges being laid. 

Who was Troy Bourque? 

Six days after the accident that took his life, Bourque and his wife Corry Ellen would have celebrated their 15th wedding anniversary. 

"But instead we spent it at York Funeral Home, where well over 800 people paid their respects. And said goodbye to Troy," she told the inquest jury Tuesday. 

"Troy, he was that guy. You met him once and he left a lasting impression on you." 

Ellen was the final witness to testify in the inquest into Bourque's death.

She described her husband as her soul mate. 

"Even though our years together were short, I can honestly say we really had the best relationship, we shared everything," she said.

She said Troy was always cautious and never reckless. 

"I guess that's why this is so hard to understand," she said. 

Corry Ellen Bourque, at right, said she and Troy were soul mates. (Roger Cosman/CBC)

When she cleaned out his car, she found four first aid kits. 

Together, she said, they liked to go on motorcycle trips, and they enjoyed taking their daughter out in their pontoon boat. On one outing, Troy rescued a father and son who had capsized a sailboat. 

He was the type of person who would help friends move or renovate, she said. He helped coach his daughter's volleyball team and used to play in a band called Prairie Fire that he hoped to get back together. 

"He was one of a kind," Ellen said.

The president of a sawmill where Troy Bourque died in 2019 told an inquest jury today the fatal accident could have been avoided.

Bourque, who had worked at Devon Lumber for 29 years, died on Oct. 10, 2019, after being trapped between a conveyor belt cover and the bottom of a catwalk, witnesses said earlier at the first day of the inquest into his death.

About 15 minutes prior to the accident, Harry Gill, president of Devon Lumber, had been on the floor talking to Bourque, Gill testified. 

The part of the mill Bourque was attending to did not have wood running through it at the time, so Gill said he told him to work on another line.

When Gill later heard there was an accident involving Bourque, he said he went to the location he told Bourque to go to but didn't find him there. 

"Had he done what I told him, and worked on the other line, it wouldn't have happened," Gill said.

Witnesses explain how Bourque got trapped

Prior to Bourque becoming trapped, the mill's line had been shut down, which meant no wood was running through it but machinery was still in operation, according to Spencer Gill, an employee at Devon Lumber. 

When the line is shut down, employees usually use the time to clean up their work area, testified Michel Cyr, acting assistant director of investigations at WorkSafeNB. 

Gill said that once the line shut down, Bourque waved him over for help because he had noticed a metal cover for the conveyer belt had come loose. 

The two grabbed the cover, which would have weighed about 120 pounds, and attempted to put it back into position, Gill testified. 

Devon Lumber after the workplace incident in 2019. Company president Harry Gill said two recommendations from WorkSafeNB have been implemented. (Joe McDonald/CBC)

Gill said the cover somehow came free and fell onto a moving chain going toward Bourque, who was in a less than three-foot-tall space below the catwalk. 

"I could see that it was coming right for Troy," Gill said. "So I hollered at him. But the way that he was situated in there, kind of on his knees, there was — there was nowhere for him to go."

Cyr testified that the cover made contact with another cover that pushed it upwards.

It then struck Bourque in the neck and chest area, Cyr said, pinning him underneath the catwalk. 

"So he got trapped, and when we showed up that's where he was," Cyr said.

Angela Miller, the forensic pathologist who completed Bourque's autopsy, testified that his cause of death was severe blunt, crushing head, neck and torso injuries. 

Tried to unknowingly fix cover incorrectly 

Gill testified that he had never seen this cover out of place before, which he said lead to them not knowing how to put it back on properly.

"We were putting it in the wrong place, which neither of us knew," Gill said. 

The inquest into Troy Bourque's death at Devon Lumber will continue until Jan. 18. (Joe McDonald/CBC)

The cover they tried to fix had a notch which corresponded with a post on the cover it would go up against, Gill said. 

"And we didn't see that. So we couldn't put the plate down properly as we thought we were," Gill said.

Conveyor should have been off to fix cover, president says

Harry Gill also said that Bourque could have told him about the issue with the cover, had he noticed it when they spoke, and all machinery would have been shut down and locked so it could be fixed. 

"But in this this case here, where these guys took it on on their own, not only was it not locked out, it wasn't turned off, there was — nobody knew they were doing it, it wasn't reported to maintenance."

Gill said the cover is now permanently welded in place, and a restricted-area sign has been placed where Bourque went to try to fix the cover, both recommendations made by WorkSafeNB. 

The inquest is scheduled to run until Jan. 18.