As 25-year-old Zak Muise set off on a utility terrain vehicle (UTV) that would ultimately end his life, he wasn't wearing a helmet and was riding in a vehicle with damaged retention netting that was not properly inspected, according to a WorkSafeBC report.
Muise, originally from Waterford, Ont., died when the UTV rolled over on July 28, 2023, as he helped battle the massive Donnie Creek wildfire in northeastern B.C.
"Loved by many," he is survived by his parents and five older siblings, according to an online obituary posted at the time of his death.
The report by the workplace safety agency, obtained by CBC News through an access to information request, says the B.C. Wildfire Service, the prime contractor of Muise's worksite, "did not provide adequate supervision of the operation of UTVs and thus did not ensure the health and safety of the workers performing work at the workplace."
UTVs are four-wheeled utility vehicles with lots of storage space commonly used to haul equipment and supplies in difficult terrain.
The conclusions come as another WorkSafeBC report into the death of 19-year-old wildfire fighter Devyn Gale found several safety failures leading up to her death last summer.
4-metre drop
Muise was working for contractor Big Cat Wildfire at the time of the incident. He and his supervisor had left a water pump site about 150 kilometres north of Fort St. John on the UTV to get more fuel.
The WorkSafeBC report redacted who was driving the UTV.
According to the report, a pickup truck was travelling west on a gravel road toward the UTV as it was travelling east.
To avoid the truck, the report says the UTV drove off the road through a ditch to take a detour that led back to the worksite. But the driver saw a four-metre drop directly in front of him and applied the brakes.
"The UTV was unable to stop, and it continued over the edge of the steep embankment drop-off," the report said.
As it went over, the report says the driver-side front tire dug into the side of the ditch, causing the UTV to shift. The rear of the vehicle swung around and crashed into the ground, with the UTV rolling onto the passenger side.
The UTV was equipped with door netting on each side, intended to reduce the probability of a person's head, upper torso and limbs from being trapped between the vehicle and the terrain in the event of a rollover, according to WorkSafeBC.
However, the quick-release clip for the passenger-side netting was damaged before the incident.
"At the time of the incident, the netting was tied onto the clip rather than being properly attached and was ineffective," the report said.
WorkSafeBC said one of the men in the UTV, whose identity was also redacted, wasn't wearing a seatbelt.
It says the BCWS was required under the Occupational Health and Safety Regulation to ensure workers used seat belts and netting.
UTV not inspected
BCWS's off-road vehicle training program does not include UTV use, according to the report.
A copy of the manufacturer's owner's manual was found at the incident site, which clearly outlined the requirement for workers to wear helmets approved by the U.S. Department of Transportation, seat belts and have retention netting, the report said.
Three of those helmets were provided to BCWS. "However, the helmets were not used … on the day of the incident," the report said.
WorkSafeBC says BCWS also did not ensure that UTV operators completed pre-use inspections of the UTV.
It says the inspection "would likely have identified" safety gaps.
BCWS is required to include appropriate written instructions, available for reference by all workers, the report said, to supplement the Occupational Health and Safety Regulation.
But the fire service did not provide any written safe work procedures or policies specific to the safe operation of UTVs, according to the report.
"BCWS knowingly allowed workers to operate mobile equipment without the benefit of specific UTV safe work procedures," the report said.
"Had BCWS developed and implemented safe work procedures for the safe use of UTVs, those procedures would likely have included requirements for pre-use inspections, use of seat belts, use of retention netting, and use of safety headgear, as well as processes for correcting deficient items and removing UTVs from service."
Safety of crew members 'first priority'
Bruce Ralston, B.C.'s minister of forests who is responsible for the BCWS, told CBC News that the safety of fire crew members is the "first priority."
His statement, in part, said the service is increasing personal protective gear and strengthening training opportunities.
The ministry also says that training has been expanded to ensure supervisors and staff have training specifically on the operation of UTVs. In addition, it says inspections of UTVs are being required before they're used.
Rob Schweitzer, the assistant deputy minister for the BCWS, said "last year's fatalities serve as a stark reminder that this work is never done."
"It is my job to ensure that everyone from crew members to support staff can carry out their work in as safe an environment as possible. I am dedicated to ensuring this work continues throughout this summer and years to come," he said in a statement.