“I know 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 to the injuries, but we feel it would lead to a safer environment,” chief coroner Clive Weighill said.
The office has made recommendations to six different government agencies after reviewing the crash.
The coroner also says the Ministry of Highways should review its policy on signs at intersections and Saskatchewan Government Insurance should implement mandatory truck-driver training.
There is a recommendation that the chief coroner create a mass fatality plan and that the Saskatchewan Health Authority review how it identifies the dead and injured in such an event.
Evan Thomas of Saskatoon was among 16 people killed last April when a semi truck barrelled through a stop sign at a rural crossroads north of Tisdale and into the path of the junior hockey team’s bus. Thirteen others on the bus were injured.
“A tragedy this size, it can’t just be one thing that went wrong,” his father, Scott Thomas, said Monday.
Thomas said the coroner’s findings provide him with a sense of justification for some of the things that he and other families have been hoping to change.
What hit home for Thomas are the recommendations directed to Transport Canada for mandatory seatbelts and improving national safety codes for driver training and electronic logging.
“To me this has to be a nationally regulated profession and these guys should be treated as professionals just like airplane pilots are.”
Thomas said he believes Jaskirat Singh Sidhu, the truck driver who is waiting to be sentenced for causing the crash, never should have been behind the wheel in the first place.
“He never should have been responsible for a vehicle of that size on that roadway, and somehow the system allowed for it.”
WATCH: Saskatchewan chief coroner speaks about Humboldt report, calls for seatbelts on buses and better victim ID system
In December, the Saskatchewan government announced it will make training mandatory for semi-truck drivers starting in March. Drivers seeking a Class 1 commercial licence will have to undergo at least 121 1/2 hours of training.
Transport Canada announced in June that the department will require all newly built highway buses to have seatbelts by September 2020. Some charter bus companies say many new vehicles already have seatbelts, although there is no way to ensure passengers are wearing them.
In a statement, Transport Canada added that they are developing a national standard for entry-level commercial drivers. That is expected in January 2020. The federal agency is also finalizing technical standards for electronic logging devices. That is scheduled to be released by spring, 2019.
Since the crash, Thomas and other Broncos families have been spreading the message to other sports teams to buckle up and some have taken up the challenge.
Another recommendation calls for the chief coroner to create a mass fatality plan and for the coroner’s office and health officials to review how they identify the dead and injured.
Days after the crash, the coroner’s office apologized for mixing up the body of a player in the morgue with an injured player in hospital. Xavaier Labelle was mistakenly declared deceased, and identified as Parker Tobin. When Labelle regained consciousness on April 8 he revealed his identity. Tobin lost his life in the crash.
WATCH: Coroner says experience did not come into play in Humboldt mix-up of identities
Weighill said the error came in part from pressure from the media and public to identify the victims. He said the crash took place on a Friday night and a memorial was already planned for Sunday night.
“There was uncertainty of the one family. We were working with that family on the Sunday. It was set up for dental records to be examined on the Monday for a positive identification. So we had really not completed the whole process by Sunday night when the memorial was going to happen,” Weighill explained.
The Saskatchewan Health Authority once again apologized for the mistaken identity and said they will be accepting Weighill’s recommendations. Weighill suggested in future mass causality incidents no names will be released until identities are 100 per cent confirmed.
WATCH: Global News video coverage of the Humboldt Broncos tragedy
Thomas said he would like to see the coroner’s report made binding. A coroner’s report into a crash at the same intersection that killed six people in 1997 recommended installing an additional warning device such as rumble strips. The government at the time declined.
“If the government would have acted after the ’97 coroner’s report, rumble strips would have been there. And I got to think that would have significantly changed the outcome of that day,” said Thomas.
In a statement, the Ministry of Highways said they received an engineering review of the Highway 35 and 335 intersection in December. They will be moving forward with all 13 recommendations from that review, which include mill rumbles strips on Highway 335 and larger “stop” and “stop ahead” signs.
The statement adds the Saskatchewan Highway Patrol is currently undergoing a review of all policies and procedures, including stricter compliance regulation.
The coroner’s report lists the deaths as accidental and says the chief coroner is not calling for an inquest.
-With files from Global News’ David Baxter