Coroner's report into Humboldt crash focuses on ID mix-up, transportation safety

The Saskatchewan Coroners Servicehas completed itsinvestigation into theHumboldtBroncos collision. It released six recommendations and announced that no inquest will be held.

The April 6, 2018 crashbetween theHumboldtBroncos team bus and a semi trailerkilled 16 people and injured 13others.

JaskiratSinghSidhu, the driver of the semi involved in the crash,pleaded guilty to 16 counts of dangerous driving causing death and 13 counts of dangerous driving causing bodily harm.Sidhu started working for Calgary-based Adesh Deol Trucking Ltd. three weeks before the crash.

Therecommendations in the coroner's report are directed toward SGI, Saskatchewan Health Authority, Transport Canada, the Chief Coroner, Saskatchewan Highway Patroland the Ministry of Highways and Infrastructure.

Some of the points have already been partially addressed by the agencies.

Policy reviews, mandatory seatbelts

The report recommends the Ministry of Highways and Infrastructure review its policy onsigns and traffic controldevices at the intersection where the collision occurred. The ministry has already done so.

Theintersection of Highway 35 and Highway 335 has become a makeshift memorial to the 16 people who died from the crash.

The report alsorecommends that Saskatchewan Highway Patrol ensures stricter compliance with rules and standards for commercial truck drivers likeSidhu.

It recommended SGIimplement mandatory training for truck drivers. This has already been done and is scheduled to come into effectMarch 15.

Transport Canada is developing a national standard for entry-level training for commercial drivers by 2020.

The document recommendsTransport Canada push for stricter safety regulations on the electric devices that log the time drivers spend on the road. In an emailed statement, Transport Canada saida technical standard for electronic logging to "reduce the risk of driver fatigue" will by finalized by this spring.

The recommendations also include a specific reference to seatbelts in buses, asking that Transport Canada make installation of seatbelts mandatory on buses like the one involved in the Broncos crash. While that move is already scheduled byTransport Canada to be implemented by 2020, it is unclear whether older buses and all coach buses will be included.

Chief Coroner Clive Weighill saidduring a press conference following the report's release that he'dliketo see every bus in Canada outfitted with seatbelts.

"It stands to reason that if people are belted into their seats it's a safer occurrence, if they're in an accident," Weighillsaid.

He also stated he would oppose any kind of grandfathering of old buses without seatbeltsand would instead like to see the safety devices installed in them.

Petition calls for stricter regulations

DaynaBrons,the only female passenger on theHumboldtBroncos bus on April 6, 2018, wasone of the 16 people killed. Her parents are part of a group of Broncos families who are supporting a petition pushing for strict trucker training guidelines.

Saskatchewan has enhanced its guidelines for training. Starting March 15, it will be mandatory for potentiallicence holders to complete a minimum of 121.5 hours of instruction, but only in Saskatchewan.

"Ifone province or the other is going to do it, what's stopping anybody from going to the next province and moving there and getting their license there," said Lyle Brons, himself a former truck driver.

Beyond mandatory training, the families are also seeking graduated licensing. The petition does not include mention of seatbelts, but Bronssays it's part of what he's campaigning for.

"We feel that's another way that we can hopefully prevent any more injuries and deaths in situations similar to this."

Mass fatality plan

After the collision, families scrambled to find out the condition of their loved ones. The family of Parker Tobin, a Bronco player from Alberta, sat at the bedside of a player they thought was their son, but who turned out to be his teammate Xavier Labelle. Tobinhad died in the crash.

It was previously recommended that Saskatchewan Coroners Servicecreate a mass fatality plan and train staff accordingly. Monday's report specifically mentioned identification of the dead again.

According to Weighill, a plan is in the works and should be completed by the end of March. He said his office is working with SHA and the RCMP to ensure that all necessary protocols are followed collaboratively.

"If it's not a homicide then it's a coroner service that actually takes charge of the scene," he said

"When there's a very tragic event and there's a lot of things happening sometimes that communication can break down."

He told reporters that after the Broncos crash on April 6, the office had to rely on the hospital to make positive identifications. Media, the publicand families were impatient for the identifications to be made. In the future, he said, those identifications will take more time.

"Things will be much, much slower. In the future we will not identify anybody and put anything out until we are 100 per cent positive."

The Saskatchewan Health Authority is also singled out and encouraged to review their policies around identifying the dead after a mass casualty event.

An emailed statement from the SHA says the body "accepts the recommendation" and "will make every effort to strengthen our policies and procedures around patient identification in these very difficult situations."

It also includes an apology to the people affected by the ID mix-up and says there will be steps to ensure it doesn't happen again.

Broncos families have been provided with the Coroners Service report.