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Police officers stand at the scene after three people were overcome by an unknown substance and died at a mushroom farm in Langley, B.C., in 2008.

Darryl Dyck/ The Canadian Press

An industrial accident at a mushroom-composting facility that killed three men and left two others with irreversible brain damage was the culmination of years of neglected worker safety and inherent design flaws, a new report from WorkSafeBC concludes.

And a fragmented regulatory regime resulted in a series of "missed opportunities" to prevent the tragedy at A-1 Mushroom Substratum Ltd. in Langley.

The damning report offered no comfort to Tracey Phan, whose father has been in a coma since the incident three years ago. She said the findings won't encourage vulnerable agriculture workers to speak up about dangerous working conditions.

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The five victims were all fathers of school-aged children: Jimmy Chan, Ut Tran and Han Pham died in a shed after being overcome by a combination of toxic gas and low oxygen. Michael Phan and Thang Tchen are permanently disabled.

"The government needs to inform all these employees that they need to put themselves first and that they should not be afraid to speak up if something is wrong," said Tracey Phan, who is 15. But that message is hard to get across, she said, when employers face only minor repercussions for failing to protect workers.

The employers have avoided jail time. The report was released Monday, three days after the courts fined two companies and three individuals who operated the Langley, B.C., mushroom farm. It is unclear how much of the $350,000 will be collected because A-1 Mushroom is now bankrupt.

"Last week people were looking for justice; they didn't get it," said Jim Sinclair, president of the B.C. Federation of Labour. "This week they were looking for a legacy so this doesn't happen to somebody else – and they didn't get any recommendations in this report to fix things."

The incident occurred on Sept. 5, 2008, when two workers were sent into a pump house to fix a blocked pipe carrying recycled "brown water" to a composting barn. The pair managed to open a valve when one of them called out to their supervisor, standing at the entrance, that there was a strange smell.

By the time an ambulance crew arrived 20 minutes later, four co-workers had attempted their own rescue. Five men were collapsed inside the shed, and a sixth man made it outside, struggling to breathe. Others tried to go in but were blocked by emergency responders, who recognized the hazards.

Since opening in 2005, A-1 Mushroom had run afoul of a string of regulatory requirements from municipal, regional and provincial arms of government. Just hours before the fatal incident, neighbours who had complained about the smell were promised that the owner was preparing to shut down the operation in the face of a court challenge by the Township of Langley.

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In its report, WorkSafeBC concluded the workers at the farm had no health-and-safety program and no knowledge of the potentially lethal hazards they faced. When they complained about eye and throat irritation, workers were given dust masks and goggles and told to "be careful."

However, the 61-page report offered only passing acknowledgment of WorkSafeBC's role in failing to protect workers.

The agency received four complaints and twice sent an inspector, but it never saw the pump house where the men died. A city inspector expressed concern for employees working without any protective equipment, but WorkSafeBC inspectors opted not to visit the site again.

Jeff Dolan, director of investigations for WorkSafeBC, said the employer is responsible for ensuring compliance with occupational safety, but the remaining seven mushroom composting facilities in B.C. now face rigorous inspections. "Inspectors are following the pipes from start to finish."

Labour Minister Margaret MacDiarmid called the incident an entirely preventable tragedy.

"There were a whole bunch of things, a number of small things and some bigger things, that conspired for this to happen," she said, adding that she needs more time to digest the report before deciding whether government action is required. However, she said it is clear employers need to be more informed about the hazards of confined spaces, which have killed 16 workers in B.C. in the past decade.

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