The investigation was flawed, the conclusions were jumped to and policies were ignored, but it isn't enough to change the outcome of a 15-year-old workers' compensation board case.

In a ruling released last Friday, the Workers' Compensation Appeal Tribunal upheld the conclusion that former Yukoner and Golden Hill Ventures employee Robert Els took his own life while on the job in November 1995.

"We agree that the investigations were not up to the standard we would expect from these parties,” the three-person panel said in its 26-page ruling.

"However, we also recognize that if the investigations were faulty, it does not necessarily mean the conclusion is also faulty.”

Els' daughter Angela was granted a fresh hearing of her father's case in front of the appeal tribunal after the Yukon's Ombudsman said the first appeal hearing was tainted when chair Ed Sumner discussed the case at a curling bonspiel.

During the rehearing, held in August of this year, the Yukon's workers' advocate, Julie Docherty, pointed out numerous flaws in the investigation into Els' death, and brought forward two similar cases where a suicide ruling was overturned.

(Full disclosure: I attended the hearing during my summer holidays at the family's request. Although these hearings are not normally open to the public or the press, I was permitted to stay because the family argued I was there as an observer on their behalf.)

Docherty began with a litany of errors and oversights made during the police, coroner and workers' compensation board (WCB) investigations into the death.

From the get-go, Els' co-workers speculated he had killed himself and the police accepted that conclusion seemingly without question, she said.

Els' was a "loner” who didn't seem to have many friends, his colleagues told the police, but as Angela's mother pointed out this week, Els had good reason to avoid socializing with the crew.

"He didn't want to drink,” Lynn MacKinnon said after reviewing the decision document. "He kept to himself because he didn't want to be around people who were boozing it up after work. He wanted to get out of that life.”

MacKinnon thinks the police jumped to the conclusion that Els killed himself (two officers came to her house just six hours after he was found to say he had taken his own life), then simply looked for evidence that would support their theory. She points to the so-called "suicide note” as

proof of that error.

A letter from Els' sister found in the cab of his truck was labelled a suicide note by police, even though it was clearly addressed to Els and made no mention of anyone wanting to die.

The mistake – which made it into the preliminary death report and the official police report – was then copied into the coroner's report which was relied on by the WCB.

It was a "gross error,” Docherty said, which tainted each level of investigation.

In fact, she said, the investigation pretty much came to a halt with the police.

Under the Occupational Health and Safety Act, the WCB is supposed to conduct its own investigation into a workplace death, but that didn't happen in this case.

Docherty pointed to a memo from the occupational health and safety manager to the WCB's lawyer.

"When RCMP declared it a suicide, we quit the investigation .... Because the RCMP took the lead and declared it a suicide, we did not do much.

"We have no formal report because of the RCMP decision .... There was no mechanical reports. (The safety officer) spoke with (Golden Hill's lawyer) and he was refused access. We did not pursue because of circumstances.”

The note does not explain what the "circumstances” were.

What Docherty didn't mention at the hearing is that for years, the WCB has been telling MacKinnon and Angela Els that it has no authority to make a finding different from that of the coroner.

When the Star published a story about the case earlier this year, WCB spokesman Mark Hill asked the paper to print a clarification explaining that the board can't contradict a coroner's finding.

The Star never published the clarification because it is not true.

Under its legislation, the WCB and the appeal board are independent and can make their own findings based on the evidence. The Yukon's then-coroner made this clear when he reviewed Els' case in 2004.

Contrary to the WCB memo, a mechanical report was done by Golden Hill's own mechanic, who said there was nothing wrong with the truck which would cause it to unexpectedly lower the box.

Not only was the 134-word report unsatisfactory, Docherty said during the appeal, but it should not have been done by another Golden Hill employee. MacKinnon agrees.

"They checked their own equipment,” MacKinnon said this week.

"How is that right? I think they fixed their own equipment; they fixed their own junky truck to protect themselves.”

Though there was no evidence ever found to support MacKinnon's claim, she believes it is a reasonable one the tribunal should have considered.

"I just think they do whatever they want, and it's a cover-up.”

She said she believes the truck was "moved and fixed up .... I don't think anyone could have done that in eight seconds.”

She is referring to the fact Els would have had eight seconds to activate the box lever from inside the truck, get out the passenger side door and crawl under the box before it lowered.

"Why would someone kill themselves like that?” is the question MacKinnon said has never been adequately answered.

Other inconsistencies pointed out by Docherty include the fact that investigators said they only found one set of footprints on the catwalk leading from the passenger-side door to the place where Els was found, and none were found on the ground below.

This is impossible, she said.

Firstly, one employee said she "walked around on the catwalk” before finding Els' body. Then, at least one other employee told investigators he circled Els' truck looking for him that night.

How, Docherty asked, could there be no footprints if at least two people say they walked around the truck before police?

Furthermore, she said, the safety officers' report states "the box (on Els' truck) was raised and half-full of frozen dirt.”

But statements by two other employees say the box was lowered and empty. It was another employee's truck which had the frozen load, and the safety officers had their facts muddled, Docherty said.

Then, there is the problem of the truck being moved.

On the night Els died, several employees noted that his truck was standing idle with the door open, but Els was nowhere to be seen.

At least one person said she walked around the site looking for him, worried he may be injured and hidden behind one of the dirt piles or pieces of equipment.

"Seeing that there was no sign of him around the truck, we had to move it out of the dump area, so as the other trucks could continue dumping,” the company's heavy-duty mechanic told the safety officer. "I moved the truck about 100 metres and parked it out of the way.”

That proves there was no reliable scene investigation, Docherty argued. The police and safety officers relied on secondhand descriptions of the truck's original location.

Each investigator's report was based on a previous flawed one, with mistakes being compounded at each stage.

But everything Docherty brought to the appeal was overshadowed by Els' daily journal, which he kept as part of his Alcoholics Anonymous program.

The last entries in Els' journal "revealed his disorientation from reality,” the tribunal members said.

"... Notes written by the worker also indicated a deterioration in his mental state and his inability to accept reality,” they write in their ruling.

In their final analysis, they note contradictory opinions of two counsellors: one who met with Els and said she saw no indication he was suicidal, and another, who never met Els, but read his diary and said Els "appeared to have lapsed into a state of paranoia and distrust, doubting the sincerity of even closest friends and family.”

MacKinnon disputes the second opinion, pointing out that Els had spoken to his father about a Christmas vacation just days before his death.

The tribunal, however, ruled out the possibility of an accident or homicide and agreed with the suicide opinion.

"We have already expressed our concern with some of the investigations that were undertaken as well as the speed of the conclusion arrived at by investigators,” they write in the conclusion.

"We also reiterate the fact, stated earlier in our preamble to our analysis, that although the investigations may not have been up to our expectations, the conclusion reached may not necessarily be wrong.”

The Els' appeal was heard by Hank Leenders, Margaret McCullough and Helmer Hermanson.