It's now up to five members of a coroner's jury to sift through a morass of contradiction, alleged neglect and missed opportunities to determine what should be done differently to prevent another accident like the one that killed three mushroom farm workers in 2008.
Testimony at the inquest into the deaths wrapped Tuesday with tearful family members begging for workplace safety improvements.
"Today I'm not here for my benefit, I'm here to help the people who are still working," said Nga Trieu through an interpreter.
Trieu's husband, Han Pham, was one of three farm workers killed on Sept. 5, 2008, when hydrogen sulfide gas was released from a pipe in a composting facility pump house.
'When you look at that farm, I would say they just about got it all wrong.' —B.C. Federation of Labour president Jim Sinclair
Pham, Ut Tran, and Jimmy Chan died from the gas release, while Michael Phan and Thang Tchen were left severely brain damaged.
"A lot of Vietnamese workers don't speak English and cannot find work," said Trieu. "They have to work at mushroom farms, and whatever treatment they get from the boss, they have to suffer."
Added Tran's wife, Hong Dang: "Every time I think about the accident, I cannot breathe. But I've been trying my best to come [to the inquest], because I'm thinking about the families of other workers."
The three family members told jurors they are struggling to get by on the income provided by the Workers Compensation Board, and urged further protection for farm workers.
Jim Sinclair, the president of the B.C. Federation of Labour, told the inquest earlier in the day there has been some pressure on the families from the Vietnamese farming community to keep their dispute within the community and not make a fuss at the inquest.
Sinclair thanked the family members for their courage in testifying at the inquest.
"When you look at that farm, I would say they just about got it all wrong," Sinclair said.
Series of missteps
Over seven days of testimony, jurors heard of a series of missteps that led to the likelihood that someone would get hurt.
Jurors heard the chief investigator for WorkSafeBC testify many more could have been killed or injured that day.
Ha Quan Truong, the farm's owner, told the inquest he relied on his managers and supervisors to keep the farm running safely and within regulation.
The farm had no safety procedures in place and had repeatedly failed to send monitoring reports as required by provincial regulations on composting facilities.
Many other people who spoke at the inquest, including D'Arcy Ashe, the farm's former general manager, portrayed Truong as a stubborn, neglectful owner unwilling to spend money on safety and maintenance equipment.
Ashe told the inquest no expense had been spared when building the composting facility, but a contractor and an environmental engineer both said the facility started malfunctioning within months of its opening in November 2005.
The inquest heard the facility never received a final inspection by the Township of Langley and began operating without an occupancy permit.
The township first sent a letter to Truong in September 2006, ordering Truong to cease operation until an inspection was passed.
Over the next two years, Truong and the township were in a constant struggle to bring the farm into compliance with bylaws and regulations.
During Truong's defiant testimony, which was done through an interpreter, he told the jury he had always followed the township's instructions, despite evidence of two separate court actions against his farm.
"Don't say that I didn't do what I was asked to do," Truong angrily told Ryan Berger, the township's lawyer at the inquest. "If I did something wrong, the police would have arrested me."
In 2008, the township's general inspector was visiting the farm almost daily, documenting its regulatory breaches.
The inquest was told the composting facility's piping system was clogging every two to three weeks with straw and manure.
On Sept. 5, 2008, when workers were killed by the gas release while trying to unclog a pipe with a screwdriver, the township's lawyers were in court trying to have the facility closed.
It was scheduled to shut down the day after the accident.
Truong told the inquest he lost everything due to the accident. He asked family members not to think of him as an enemy, saying he had been victimized too.
He said he was sorry the workers died and said he felt the family members' pain, saying he didn't know the accident would happen.
His words fell flat with his workers' families.
"We can't go home and turn the page," Tracey Phan, daughter of the wheelchair-bound Phan, said Tuesday.
"I don't want this to happen to anyone else. No 'I'm sorries,' no 'I understands' can ever make it up."