A report by the coroner's office is calling for a mass casualty plan and mandatory seatbelts on buses after the Humboldt Broncos bus crash.

The coroner has determined the 16 victims died as a result of injuries sustained in the crash.

The manner of death has been ruled accidental.

Sixteen people were killed and another 13 were injured when the Broncos team bus collided with a semi-trailer at the intersection of Highway 35 and Highway 335 on April 6.

The driver of the semi, Jaskirat Sidhu, pleaded guilty to all 29 charges in the crash on Jan. 7. The Crown asked for a 10-year prison sentence for Sidhu at an emotional sentencing hearing last month. Justice Inez Cardinal reserved her decision to March 22.

Recommendations from report

The coroner’s office released six recommendations in its report into the Broncos crash.

Scott Thomas, whose son was Evan was killed, says he hopes the recommendations will prevent other tragedies in the future.

“It is encouraging that hopefully some positive changes can come out of this and nobody ever has to go through it again like we have,” he said.

The office wants the Ministry of Highways and Infrastructure to review its policy on the installation of traffic control devices and signs at intersections. The province received 13 recommendations to improve safety at the intersection from a separate report.

The coroner is also asking for Saskatchewan Highway Patrol to ensure stricter compliance for regulations and standards for commercial drivers.

Mass casualty plan

The Saskatchewan Coroners Service should have a plan to train staff for a mass fatality plan, the report recommends. This includes identifying the deceased after the crash.

“Our mass fatality plan is almost complete at high level,” Saskatchewan Chief Coroner Clive Weighill said. “We should have that by the end of March.”

The coroner’s office misidentified one of the crash victims as Xavier Labelle in the immediate aftermath of the crash. On April 8, the office said Parker Tobin had died and Labelle was recovering in hospital.

“I can say, probably from now on, everybody that would come in is going to be a Jane Doe or a John Doe until we have a positive identify on each person,” Weighill said. “We were trying to identify people as quickly as we could.”

The process for identification will slow down, Weighill said, to make sure everyone is 100 per cent positive on a victim’s identity.

Weighill added he wants to make sure people understand the roles of the coroner’s office, the health authority, the RCMP and others during mass casualty events like the bus crash.

The report also asks for Saskatchewan Government Insurance to implement standardized truck driver training in Saskatchewan. The province announced late last year that it would bring in mandatory training of 121.5 hours starting March 15.

The fifth recommendation from the report asks the Saskatchewan Health Authority to review its policy on identifying people in its care following a mass casualty or fatality event.

National safety regulations

Finally, the report asks Transport Canada to improve national safety regulations on driver training and electronic logging, along with installing mandatory seatbelts on public transit buses travelling on highways.

“A lot of the injuries were because people were ejected from the bus,” Weighill said. “I know that there was a lot of damage done to the bus, but still, people were thrown about and thrown and ejected from the bus. We can’t say for sure if that would have made a big substantial difference or not to the injuries, but we feel that it would certainly lead to a safer environment.”

"It could happen anywhere, anytime," Thomas said. "Seatbelts should be a no-brainer. They should be on (buses)," Thomas said.

Weighill added his office hasn’t heard back from Transport Canada yet. It would be up the legislative assemblies in each province to adopt the changes.

All parties involved in the recommendations have been notified.

Weighill also said every family received a separate report from the coroner, along with a copy of the autopsy report and a report on the cause of death of their loved one.

The chief coroner says there will be no inquest into the deaths, since there would be nothing to gain from a public hearing.

Transport Canada responds

“Transport Canada welcomes the recommendations made by the Saskatchewan Coroners Service as a result of its investigation into the tragic collision involving the Humboldt Broncos junior hockey team,” spokesperson Sau Sau Liu said in a statement to CTV News.

In January 2019, the Council of Ministers responsible for Transportation and Highway Safety agreed to develop a national standard for entry-level training for commercial drivers by January 2020; and finalize a technical standard for electronic logging devices to reduce the risk of driver fatigue by Spring 2019, Liu said.

In July 2018 Transport Canada published a regulation making seatbelts mandatory on motor coaches, Liu said.

 “Consistent with the Coroner’s recommendation, this regulation brings Canada fully into alignment with motor coach safety requirements in the United States, and goes a step further to include medium-sized motor coaches in the Canadian rule.”