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Elliot Lake commissioner lambastes emergency response

Oct. 15, 2014, Elliot Lake, Ont. – The emergency response to the collapse of the Algo Centre mall was poorly executed and only intervention by former premier Dalton McGuinty after the search had been called off led to the resumption of the operation, inquiry commissioner Paul Belanger said Wednesday.

“The premier of Ontario, the premier’s office and other provincial authorities acted with leadership, genuine compassion and assistance when hope seemed lost,” Belanger said.

The 644-page report on the response to the June 23, 2013, collapse lambastes almost every aspect of emergency management in Ontario relating to the incident. Among the 34 recommendations are mandatory incident command, mandatory after-action reports and restored federal funding for HUSAR teams.

Belanger said Lucie Aylwin, one of two women who died in the collapse, might have survived had responders moved more quickly.

Belanger’s frustration with a far-from-perfect emergency management system was clear.

“During the response, a congruence of errors – some minor, some more important – led to a rescue effort that was no model of perfection,” he said.

“As a result, questions will long persist about he possibility that Lucie Alwyin could have been rescued.”

The report – two volumes totaling almost 1,400 pages with part 2 focusing on the response – is relentless in its criticism.

“In my view, the Ontario emergency response system, particularly in the area of urban search and rescue, is in need of an overhaul,” Belanger said.

However, Belanger said, his criticisms of the response to the collapse do not mar his respect for first responders.

Indeed, Belanger noted that Elliot Lake Fire Chief Paul Officer’s nomination of some of his firefighters for the Ontario Medal for Firefighter Bravery had been put on hold until the commission completed its work.

“These awards should wait no longer,” he said. “Those commendations are richly deserved.”

Belanger was not critical of the Elliot Lake Fire Department or its response. In fact, he said, the department’s actions were prompt and efficient.

Belanger also lauded the quick response by the OPP’s search and rescue team –called UCRT.

“The . . . speed of deployment was remarkable,” he said. Earlier in the report, Belanger called UCRT’s response time “exceptional.”

Toronto’s HUSAR team, however, took six hours to prepare to deploy to Elliot Lake, Belanger said.

“HUSAR/TF3 deployed with barely half a full team and no planning section chief,” he said. “The absence of this official had an effect on the lack of planning I observed during the mission.”

Similarly, half of UCRT’s available members deployed and the lack of a staff sergeant as unit commander complicated communication during the incident, he said.

Belanger noted, however, that communication problems were not among the workers in the hot zone, but with what he called the poor dynamics of the command structure, misunderstandings about that structure and a failure to implement the incident management system as designed.

Further, Belanger said, he noted during the seven-month inquiry that ran from March 4 through Oct. 9, 2013, that there was confusion about the command structure and a failure to adhere to and properly manage IMS, that no incident-action plan was developed, and that cranes and rigging operations could have started sooner.

Belanger said there was an inexplicable delay in ordering heavy machinery and a reluctance and lack of training in using such equipment.

The decision to bring in a crane from a company called Priestly, Belanger said, was a “last-minute, fortuitous result of McGuinty’s intervention and the fact that one HUSAR/TF3 team member knew the owner and the capabilities of the Priestly equipment.”

Belanger further dissected the response – focusing on communication, understanding of the roles of key agencies, and debriefing practices.

There was little to no record keeping during the incident, he said, which meant the commission was unable to re-create an accurate narrative; responding agencies all operated on different radio frequencies, he noted; and communication with victims’ families was irregular and, at times, insensitive.

“Lack of a well-structured communications strategy led to a real apprehension of civil unrest in Elliot Lake,” he said.

Further, Belanger noted, the rescue was called off too hastily.

“Someone was reported alive under the rubble at noon on June 25. Only hour later, a definitive end to the rescue was announced, even though key players had not yet been consulted. In the end, it was the intervention of the premier that forced rescue workers to consider a Plan B, even it if offered only a faint hope of saving a life.”

Belanger said there was “widespread and persistent confusion” about the role and actions of the Ministry of Labour (MOL) at the scene – a topic that consumed considerable time during the inquiry.

Indeed, the Ontario Association of Fire Chiefs had asked in its final submission to the inquiry that Belanger recommend that the role of the MOL be clarified to confirm whether it has the authority to stop rescue operations during an emergency response and whether that authority, if it exists, is different in a rescue  versus a recovery.

“The ministry never once issued an order preventing entry of rescue workers onto the collapse site, but the impression persisted that it had,” Belanger said.

“In fact, ministry engineers and inspectors provided useful advice and assistance throughout the deployment and acted most responsibly. There was widespread confusion about he ministry’s powers, which did in fact include the power to shut down the rescue scene in the interests of the rescue workers.

Conclusively, Belanger said, when the rescue stopped, it became clear that there was no statutory authority to make a building safe – by demolition, for example – in order to remove a body.

In a particularly harsh indictment of emergency-management practices, Belanger said he learned during the inquiry of poor debriefing practices and a lack of after-action reports by HUSAR, the City of Elliot Lake, the Elliot Lake Fire Department, the Ministry of Community Safety and the MOL. UCRT, the OPP and the Office of the Fire Marshal and Emergency Management, Belanger said, completed after-action reports.

“There were exceptions,” he said, “but some of this poor response appeared to be motived by a desire to avoid criticism and reproach.”

What’s more, he said, responders should not have discounted the expertise of Ontario Mine Rescue, a company that offered its services to help during the rescue effort.

"It is a highly trained and experienced emergency response organization with a disciplined command structure and similar skills and equipment similar to those of HUSAR/TFC and UCRT,” Belanger said.

“With a base in Sudbury it could have been in Elliot Lake in two-and-a-half hours.”

Belanger spoke at 11 a.m. Wednesday morning to dozens of Elliot Lake residents gathered at the Lester B. Pearson Centre, and was blunt.

“I heard from first responders who worked to exhaustion yet resisted and resented being ordered to stop,” he said. “ I heard from community and first-response leaders who were well-meaning but often appeared confused about their roles and responsibilities.”

Belanger said in his speech that many of his recommendations are aimed at creating a more efficient emergency-response system.

“ . . . through more rapid response times, assurance of adequate response personnel, training in different rescue techniques, enhanced communications and record-keeping, and adherence to and understanding of the incident management system through enhanced training.”

IMS will not work, Belanger said in his report, unless it is made mandatory in the near future.

And HUSAR teams, he said, should receive adequate funding; the Joint Emergency Preparedness Program funding that Ottawa has cancelled, should be reinstated, he said.

The recommendations are not binding.