OHS Canada Magazine

Ten years after boilermaker David Fifi was determined to have died of natural causes, the Workers’ Compensation Board (WCB) of Manitoba is reviewing the case following the emergence of new medical evidence indicating that his sudden demise was caused by exposure to toxic gases.

For Lila Fifi, the review of her late husband’s case was a glimmer of light at the end of a tunnel. David Fifi was working on the electrostatic precipitator (ESP) project at Vale Inco mine in Thompson, Manitoba when he died of heart attack on November 6, 2008. On that day, Fifi had called his wife Lila, who was living in Winnipeg,  complaining about difficulty breathing. “He was sick all night, he could hardly talk. He was gasping for air,” Lila recalled.

Fifi, who was in respiratory distress, called for an ambulance and was sent to Thompson General Hospital where he passed away. An autopsy report by the Office of the Chief Medical Examiner attributed Fifi’s death to natural causes by myocardial infarction due to coronary artery thrombosis. As a result of this determination, WCB Manitoba turned down Lila’s compensation claim on behalf of her deceased husband in April 2010. Manitoba Labour and Immigration’s Workplace Safety and Health (WSH) also ceased its investigation, according to a letter by Manitoba Family Services and Labour dated January 30, 2013.

Lila did not believe that her husband, who did not have a history of heart difficulties and was in good health prior to his passing, had died of natural causes. Her belief was partly guided by the fact that 49-year-old Brian Dupas, Fifi’s coworker at the same smelter, also died of a heart attack about two months earlier on September 15, 2008.

An email dated December 1, 2008 from the director of the Office of the Chief Medical Examiner in Winnipeg indicated that Dupas died of myocardial infarction. No toxicology was done as there was nothing to suggest that his death was a direct result of workplace exposure. “This unfortunately looks like two coincidental deaths due to heart disease,” the email noted.


There were also frequent gas-out incidents at the smelter where Fifi worked. According to the minutes of a meeting held on the day Fifi died, there were two gassing incidents on the previous day and that approximately half of the employees had reported feeling unwell. Since February 2008, there had been 40 major and approximately 100 minor gasout incidents. “The protocol is to leave the area when their monitors alarm” go off, the minutes of meeting stated.

“Alarms were going off all day,” Lila said, describing how the workers would run to seek shelter from gases in safe rooms when the alarms were activated. “Sometimes, there were not enough room in the safe rooms; sometimes the safe rooms were not sealed properly. You wait, and then you go back to work. Some workers could not get away, and the plumes of gas would overcome them.”

Another red flag that her husband could have been exposed to toxic substances at work were the daily conversations she and her daughter had with Fifi, who would ask his daughter to look up on the Internet about what happens when Teflon is burned. According to Lila, Fifi had mentioned in those phone conversations that Teflon rods, chairs and garbage were dumped in the furnace daily.

“Everyone is getting sick,” Lila said. “Men were vomiting in their masks when plumes of gas overcame them. The stacks were to be extended and not done, so they [gases] were getting down, drafting from them.”


Rick Ranson started work as a welder and boilermaker at the open pit mine in Thompson on March 1, 2008, sorting and welding steel plates. According to Ranson’s timeline of his tenure at the mine that he furnished on November 26, 2008, many gas-out incidents occurred throughout the months, including one that occurred on May 16, 2008 when the sulphur dioxide (SO2) monitor registered 20 parts per million (ppm).

Standards from the American Conference of Governmental Industrial Hygienists set a threshold limit value of 2 ppm over an eight-hour period and 5 ppm for a 15-minute short-term exposure limit. Sulfur dioxide is a highly toxic, colourless, non-flammable gas or liquid with a suffocating odour. At high concentrations, SO2 can cause pulmonary edema or life-threatening accumulation of fluid in the lungs. Symptoms include coughing, difficult breathing and tightness in the chest, according to information from the Canadian Centre for Occupational Health and Safety in Hamilton, Ontario.

On November 20, 2008, Ranson received a note from his doctor indicating his blood pressure was in the stratosphere and that he was not fit to return to work. “I got sick,” Ranson said. He believed that one or a combination of gases caused his blood pressure to spike, “but because of the number of heavy metals given off by the smelter, finding the gas causing it is a lottery at best.” The next morning, Ranson tendered his resignation.


Lila’s search for answers has proven to be a decade-long journey — and counting. The turning point came when Dr. Peter Markesteyn, forensic pathologist and former chief medical examiner for the University of Manitoba, penned a letter to Jon Gerrard, MLA for River Heights, Manitoba on July 20, 2018, stating that Fifi died as a result of   pulmonary edema due to exposure to toxic gases and that while myocardial infarction was a significant factor, it was not causally related to his death. “In other words, Mr. David Fifi died with myocardial infarction, not because of it,” and his manner of death was “accidental.”

Dr. Markesteyn added that the original autopsy’s conclusion was made “without the pathologist being aware at the time of the autopsy of the distinct possibility, if not probability, that exposure to toxic gases had occurred.” As the pathologist’s opinion that Fifi had died of natural causes was reached without the benefits of any clinical history and toxicology, “the officers of WPSH [Workplace Safety and Health of Manitoba] relied on that information and concluded that, as it was a ‘natural death’, no further action (on their part) was required.”

A memo dated August 17, 2018 by Dr. Teresa Pun, internal medicine consultant with Manitoba WCB, seems to confirm Dr. Markesteyn’s observation. Dr. Pun spoke with the forensic pathologist who conducted Fifi’s autopsy after WCB Manitoba received Dr. Markesteyn’s letter in July. According to the memo, the forensic pathologist advised that he was unaware of Fifi’s probable exposure to toxic gases and that he had been documented to have had clear lung sounds bilaterally, which “is not concordant with a diagnosis of pulmonary edema as a presenting symptom.”

As well, the pathologist said he did not know that an electrocardiography done on the day of Fifi’s death showed an acute ST-elevation inferior wall myocardial infarction, or heart attack. “In light of the information documented above, the forensic pathologist advised that he would not have concluded that the primary cause of death was pulmonary edema due to exposure to toxic gases,” the memo stated.

According to a Government of Manitoba spokesperson, WSH was notified that Fifi, a welder employed by Comstock Ltd., sustained a medical emergency in his home and died at Thompson General Hospital. On the same day, WSH also received a tip that workers on the smelter’s roof were feeling ill and that work had stopped.

“As part of this tip, WSH was made aware of the death of another ironworker approximately two months prior,” the spokesperson said in reference to Dupas. “Although the ironworker had worked at the smelter, the death did not occur at the workplace; therefore, [it] was not required to be reported to WSH.”

After receiving the above information, WSH initiated an inspection and preliminary investigation immediately, focusing on work conditions and occupational exposures in areas at the smelter where workers who reported feeling ill were working. As well, WSH collected information on the hazards and substances that workers may be exposed to, including the control measures in place to address the hazards.

“It was determined that Mr. Fifi had not been working in an area with a potential for high exposures on the day of his death, nor on the day preceding his death,” the provincial spokesperson reported. The Chief Medical Examiner’s determination that Fifi died from natural causes was communicated to WSH’s then Chief Occupational Medical Officer, who concurred with the decision. As a result of the attending officer’s preliminary findings, consultation with the then Director of Occupational Hygiene and the medical determination, WSH found no evidence that occupational exposures were a causal factor in Fifi’s death and discontinued its investigation.

The spokesperson added that since 2008, three Chief Occupational Medical Officers have reviewed the information that WSH has on file with respect to this incident, and all concurred with the Chief Medical Examiner’s initial determination that Fifi died of natural causes. “The Statute of Limitations under the Manitoba Workplace Safety and Health Act is two years; therefore, WSH would not re-open the investigation,” the spokesperson said.


It has been a decade since Fifi passed, but the statements from his co-workers painted a vivid picture of work conditions then. Manitoba’s WSH division interviewed Fifi’s coworkers on the day after he died, and their statements confirmed that gas-out incidents were common occurrences.

Boilermaker foreman Sean McElmoyle, who died in July 2013, said Fifi was on his crew the week prior to his death. “We got high gas at least three times a day for at least six days. All members of the crew, including myself, are ill right now.”

Boilermaker James Keck who had worked with Fifi on November 5, 2008, noticed black smoke on the roof. A few days later, Keck was admitted to Thompson General Hospital. “I was vomiting after work, I had a problem standing up, felt hot and a tingling in my hands,” Keck said.

Boilermaker Doug Bell, who was working in the 204 duct line with Fifi, reported that they were constantly gassed from at least four different stacks, but he could not confirm if there were high readings of gas on the roof.

“We don’t always have gas monitors. There must have been because you could taste it and smell it through the respirator, and it was making my eyes water,” Bell said in the statement, adding that the casing of the flue line had rotted and gases were leaking out from the holes.

That was also the week that Fifi, along with Bell and several co-workers, started feeling sick. “We have been trying to tell these guys this since we started here that something needs to be done about the gas and dust from the stacks and flue line. It’s pretty sad that someone had to die before they will look at the problem,” Bell added.

Workplace conditions in the Thompson refinery just months before Fifi’s death also raised questions about the smelter’s safety record. According to a WSH report obtained through the Freedom of Information and Protection of Privacy Act (FIPPA), former mines inspector Dennis Fontaine emailed the refinery to relate his concerns regarding two incidents involving sulphuric-acid spills on August 18 and 21, 2006.

“We consider any sulphuric acid spills as very serious,” Fontaine wrote in the email. “We are also concerned with the number of overall injuries in the refinery. For 2006, there have been 193 injuries, 88 medicals and eight disabling. What does the refinery plan to do to reduce injuries?”

Fontaine’s incident investigation report into Fifi’s death also noted that employees working on the ESP project expressed numerous concerns, including what gases were coming out of the ventilators, could these gases trigger a heart attack, why workers were not given a lung functional test prior to starting work and the lack of plant maintenance relating to leaking gases and hot dust.

The lack of repairs and deficiencies in the design and structure of the operations built by Worley Parsons was also cited by Darlene Krudzo, an Ontario-based independent investigative consultant on occupational injuries. Krudzo has been working on Fifi’s case since 2011. “I do believe that the sub-contracting arrangement involving multi-parties like Worley Parsons and Comstock contributed to diluting accountability for workplace safety that eventually led to David’s death,” Krudzo said.

In an email sent on May 22, 2009 to Mines Safety Branch of Manitoba Labour and Immigration regarding Lila’s FIPPA request that Vale Inco release certain documentation, a representative from Vale Inco Limited’s Manitoba operations explained this subcontracting structure: Vale Inco hired a third party, Worley Parsons, to manage the engineering, procurement and construction of the ESP project, and the construction company that executes most of the project’s construction work is Comstock. Fifi was a direct employee of Comstock, which was managed by Worley Parsons.

“We informed the service providers of the gases typical of a smelting operation. Procedures and practices were developed to protect the work crews. Each work crew was assigned a gas monitor, which was managed by Comstock,” the Vale representative stated in the email.

Aside from the EPS project’s complex hierarchy of subcontracting arrangements, concerns over a conflict of interest with Worley Parson’s superintendent acting as safety personnel was also voiced by workers in Fontaine’s investigation report. “Worley Parsons, who designed the facility at Vale Inco and hired the subcontractors, were in charge of health and safety,” Krudzo said. “Comstock, for example, would be reluctant to blow the whistle on Worley Parsons, because Comstock is receiving contracts from Worley Parsons and Vale Inco.”

Months before Fifi’s death, Vale Inco commissioned Pinchin Environmental Ltd. to conduct an industrial-hygiene testing within the smelter near roaster #2, in response to concerns raised by Comstock and Worley Parsons after one of the workers reported high levels of carbon monoxide (CO) at 400 ppm and SO2 at below 200 ppm from a four-gas monitor. From May 30 to June 8, 2008, monitors were set up in five locations at the smelter to collect measurements of SO2, CO, oxygen and the aggregate Lower Explosive Limit, or the lowest concentration of a gas or vapour capable of producing a flash of fire in the presence of an ignition source. Measurements were collected every 60 seconds over approximately 24 hours.

Results revealed that SO2 levels exceeding 100 ppm — considered immediately dangerous to life and health — were measured in three locations on several occasions. Elevated concentrations of SO2 measured over the sampling period appeared to be consistent with the use of roaster #2: levels were high for the first few days when the roaster was in use, remained low when the roaster was not in operation and increased when the roaster had been repaired on June 6, 2008.

“The risk of encountering concentrations in excess of 20 ppm appears to be high in all locations near any of the roasters,” the Pinchin report concluded. It recommended the use of full-face air-purifying respirators equipped with appropriate gas or vapour cartridges as the “minimum requirement” for all workers.



The second opinion by Dr. Markesteyn that Fifi’s death was accidental and caused by exposure to toxic gases prompted MLA Jon Gerrard’s letter to Manitoba’s WCB on July 23, requesting the board to “review the compensation claim made by Lila with respect to David Fifi, taking into account this new information.”

Dougald Lamont, MLA for St. Boniface also wrote to Cliff Cullen, Manitoba’s Minister of Justice and Attorney General, calling for a public inquiry into Fifi’s death to answer questions that include why Fifi’s death was classified as “natural” despite evidence to the contrary, how he and other employees were exposed to such unsafe working conditions, what processes broke down that resulted in information being withheld for eight years and who knew about the situation and dangerous conditions and failed to act.

“For many years, Mr. Fifi’s family and friends have been trying to get answers about why his death was classified as being from natural causes when there was no question that he and others were exposed to toxic gases in his workplace,” Lamont wrote.

Citing statistics that show Manitoba has one of the highest rates of time-loss injuries among all provinces in the last two decades, Lamont argued that a public inquiry would provide insight into conditions in the mine where Fifi had worked and “understand why, even with substantive rules and regulations in place, there has been a failure to adequately achieve the goals we seek in terms of safer workplaces in Manitoba.”

According to a WCB Manitoba memo dated August 10, the board has received Dr. Markesteyn’s pathology report and has submitted Fifi’s claim to a WCB medical advisor for review. Darlene Muise, manager of communications with Manitoba WCB and SAFE Work Manitoba, said the WCB could not comment further on claim matters due to privacy reasons. Vale Inco did not respond to request for comment.

“Mrs. Fifi will continue to push for a public inquiry into her husband’s death and for others,” Krudzo said. “Recommendations would have to be handed down to change this system of connections and relationships which do not promote and secure the rights of workers.”

For Lila, Dr. Markesteyn’s report could well mark the beginning of the second phase of her quest for answers. “The biggest thing that is very disturbing is that these poisonings took place affected many workers who were working to provide for their families. It would be grossly criminal to allow such horrific experience of exposures and injuries without having parties held accountable,” Lila said. “I am determined to make sure this comes to light. My worker never returned home safely.”

Jean Lian is editor of OHS Canada.


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