The fatal scaffolding collapse in 2021 at the Domtar factory in Windsor, Que., about 120 kilometres east of Montreal, could have been prevented, according to a report by the province's workplace safety board.

The report, released Wednesday by the CNESST, says the scaffolding's load was underestimated and there was an absence of vital bracing on the seventh level that would have ensured the structure's stability.

Yan Baillargeon, 39, and Hugo Paré, 22, died in the collapse and about 10 other workers were injured.

The scaffolding was constructed inside a silo at the Domtar pulp and paper plant. It fell during maintenance work  just after 1:30 a.m. on Oct. 26.

The CNESST says it contacted families and the affected companies, including subcontractors connected to the accident, on Tuesday. It says it also filed the report with several construction organizations and civil engineering firms to raise awareness of the risks.

However, Baillargeon's half-sister, Kim Baillargeon, said she was notified of the results of the investigation at the same time as the media. Regardless, she was not surprised by the report, she said. 

"Honestly, I suspected it, but the emotions rose to see [the results]," she told Radio-Canada.

"I don't really have anything to say yet other than it's unfair that two lives have been stolen by a lack of judgment by supposed professionals. My brother paid with his life"

According to the CNESST inspector, Marilyn Boulianne, the investigation was difficult to conduct because of the disordered state of the site when her team arrived.

"It is therefore impossible to determine if the structure had been modified," said Boulianne, noting that would include the addition or removal of components. 

That's because there was no inspection when the work started, but such an inspection is not required under current regulations, she said.

Weak points in the scaffold design were detected in the plans, such as the missing bracing which would have made the structure safe, said Boulianne. The importance of that bracing on the seventh level was confirmed through simulations, she said.

Quebec's order of engineers, the Ordre des ingénieurs du Québec, released a statement Wednesday that says it takes the CNESST's findings seriously and will make its own verifications to determine if further actions should be taken.

The CNESST has already proposed several ways to prevent such a tragedy. For example, it recommends that scaffolding assembly plans be signed and sealed by an engineer, in addition to being inspected before authorizing use. 

Bernard Riverin of SPE International was involved in getting the silo back in working condition after the accident. He said the report confirms what he determined in his first few days on site.

He said one of the issues is that members of any work crew on site could easily make modifications to scaffolding without authorization and that could cause failures as well.

Riverin wants more supervision of scaffolding with regulations in place that standardize the installation and maintenance of such structures, he said. This is done in other provinces, he added.

Kim Baillargeon said she's still not sure whom to blame for her half-brother's death.

"But one thing is certain, it will not be forgotten," she said.

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