Elliot Lake inquiry: Did one victim die while waiting for rescue?

The Elliot Lake Public Inquiry released its final report today, nearly 1,400 pages of damning conclusions and urgent recommendations. But there is one agonizing question that will forever linger: Did a victim survive the initial collapse, only to die while waiting for a rescue effort that was suddenly called off?

Two women were buried under raining steel and concrete when a portion of the Algo Centre’s rooftop parking lot caved in on June 23, 2012: Doloris Perizzolo, 74; and Lucie Aylwin, 37. Perizzolo died almost instantly, a portion of her hand visible to the first firefighters who rushed to the scene that Saturday afternoon. But in his sweeping report—a damning indictment of nearly everyone linked to the doomed mall, from the penny-pinching owners who neglected the leaky roof to the dubious engineers who inspected the rusting structure to the emergency personnel who literally gave up the search—Commissioner Paul Bélanger says “it is probable (although by no means certain) that” Aylwin survived for up to 39 hours, trapped under twisted debris and waiting for help.

Although the medical evidence revealed “severe” injuries to Aylwin’s body, the report concludes that none of them “was necessarily and irrefutably fatal.” Combined with “tantalizing signs of her survival” that “appear to contradict the medical evidence”—tapping noises, for example, and a faint voice heard by rescuers—it’s possible that she was still alive until the early morning of June 25, nearly two days after the roof gave way.

“If Lucie Aylwin did survive after the initial collapse, the question will always recur: Had the rescue effort been done in a different way, had it been more rapidly executed, could she have been rescued?” the report says. “The answer to that question will have to be a vague ‘maybe’ or an imprecise ‘perhaps.’ I know that is unsatisfactory, but I cannot provide a better answer.”

What is absolutely clear is that the Elliot Lake rescue effort—a round-the-clock effort that gripped the country for four dramatic days—“was no model of perfection.” Far from it, in fact. While the city’s local firefighters “acted promptly and appropriately in the immediate aftermath of the collapse,” Bélanger did not use such glowing terms to describe the Heavy Urban Search and Rescue (HUSAR) team that deployed from Toronto. Although he never questions the members’ courage or bravery, he says the overall mission was hampered by poor communication and disorganization. The deployed “numbers were not optimal, particularly at the command level,” the team lacked a coherent action plan, they failed to consider a crane as anything but a “last resort,” and their interaction with distraught family members desperate for news was “poor.”

Related post: One Step from Death: A multimedia feature on that fateful day in Elliot Lake, Ont.

Most baffling to Bélanger was HUSAR’s now-infamous decision, on the afternoon of June 25, to call off the search altogether. A structural engineer assigned to the team had warned that an escalator dangling over the rubble pile could snap at any moment, sending chunks of heavy debris onto the workers below. Toronto Police Staff Inspector William Neadles, HUSAR’s team leader, ordered the building evacuated, and rightfully so. But for reasons that remain murky, he declared the entire mission over, telling a 5 p.m. press conference that the building was too unsafe to enter and it was now up to the owner to hire an engineer to “recover” the bodies.

“Unfortunately, no alternative plan had been developed, and, with no direction, the rescuers gave up,” the report says. “What is particularly difficult to understand is why it was deemed urgent or necessary to announce a definitive end to the rescue. It would have been comparatively much easier simply to say that rescuers were taking a pause in their efforts because of safety concerns and pulling back temporarily while other options were being explored.”

Instead, the city erupted. Angry residents gathered outside the mall, screaming at firefighters and calling them cowards. It took an urgent phone call from then-Premier Dalton McGuinty to reignite therescue. “The premier’s evident concern, leadership, and insistent encouragement to explore this last possibility of rescue gave renewed hope to the victims’ families and to the community,” the report says. “He was instrumental in developing the missing Plan B.”

Plan B, it turned out, was to deploy a large, specialized crane to Elliot Lake to rip down the precarious escalator that forced rescuers to abandon the mall in the first place. Another full day would pass before that crane arrived on scene and began its tedious work. By the next day—Wednesday June 27, nearly 90 hours after the collapse—rescuers finally reached Aylwin and Perizzolo.

Related post: New evidence emerges in Elliot Lake mall collapse 

“Doloris Perizzolo’s death was unquestionably and mercifully quick,” Bélanger told an audience of community members gathered in a local auditorium—the same auditorium where, two years earlier, Neadles announced the end of the rescue effort. “But the extent to which miscues, miscommunications, and mistakes prevented the rescue of Lucie Aylwin is a difficult question…We will never confidently know the answers to these troubling concerns.”

Equally troubling—if not more—was Bélanger’s blunt assessment of the events leading up to the collapse: three decades of neglect, greed, incompetence and secrecy, culminating in a preventable tragedy so many should have seen coming. “Although it was rust that defeated the structure of the Algo Mall, the real story behind the collapse is one of human, not material, failure,” the report says. “It is difficult to resist the conclusion that, if any one of the owners, engineers, or officials who were involved with the Mall over its 33 years of existence had insisted, ‘Enough—this building will fail if it isn’t fixed,’ two lives would not have been senselessly and tragically lost. A few persons did just that, but they were ignored.”

Few escape Bélanger’s scorn. Building a shopping mall with a rooftop parking lot—and no waterproofing membrane—was “a fatal” decision and “a dismal failure form the moment it was installed.” Successive owners had the resources to repair the faulty deck but “resorted to patchwork and cosmetic solutions.” City Hall was directly next door to the Algo Centre, yet so many civic officials insisted, under oath, that they knew nothing about the building’s notoriously leaky roof that the mall “might as well have been located in Sudbury—or on the moon!”

Although some civic officials made “feeble attempts to plead ignorance,” Bélanger saw the truth: that Elliot Lake, a once-booming mining town, had rebranded itself as a retirement community—and the mall, however wet and rusty, was critical in recruiting new seniors to the city. Ordering repairs or enforcing property standards by-laws was secondary to ensuring the mall remained open. Even a year before the collapse, when two chunks of concrete fell from the ceiling in a food court restaurant, nothing was done.

“Partial or complete closure of the Mall was anathema—an attitude that percolated from the mayors down to all employees,” the report says. “The City was never an impartial arbiter between its role as a protector of the public interest, on the one hand, and, on the other, its role as the promoter of the Mall’s value to the community. The City’s enforcement responsibility was tainted by its protective instincts.”

Bélanger was particularly critical of the city’s intertwined relationship with Retirement Living, the not-for-profit corporation that oversees the effort to bring seniors to the region. Retirement Living purchased the mall in 1999 and owned it until 2005—all while various city councilors sat on its board of directors. “It appears to me to put the directors/councilors in a position of potential conflict in those instances where the best interest of the corporation differ from the best interests of the municipality,” the commissioner wrote. “Such a conflict certainly would have been the case when Retirement Living owned the Mall—for example, when there was a clear contravention of the City’s by-laws by virtue of the perpetual leaking of the parking deck.”

As Bélanger told the audience Wednesday during his prepared remarks: “The institutional and legal relationship between organizations meant to advance the public good operated to disenfranchise the city’s electorate and may have led to tolerating unacceptable conditions at the mall. Secrecy and confidentiality often trumped candour, transparency and openness.”

By the time Retirement Living sold the mall to Richmond Hill real-estate investor Bob Nazarian in August 2005, the parking deck was in a perilous state. Years of salty slush and rain had so corroded the steel beams holding the roof in place—and one welded connection in particular—that a massive failure was inevitable. Nazarian was “its last chance for structural salvation,” but “utterly failed in his role as the Algo Mall’s overseer and, in the process, put in jeopardy the lives and safety of his employees, tenants, and customers.”

He lied repeatedly, the report says: to city officials, shoppers, banks, contractors and engineers. Admitting himself that the mall was “a black hole,” Nazarian repeatedly tried to sell it, only to watch deals fall through because of his “unbridled desire to squeeze an extra dollar” out of every transaction. “His business dealings lacked scruple and integrity,” Bélanger wrote. “I know these are strong words. There are no other, more charitable terms, unfortunately, to describe his behaviour.”

Bélanger also pointed a complicit finger at the various engineers who inspected the crumbling mall over the years. Although“basic science teaches” that a combination of oxygen and water will turn any iron mass into rust—even faster with the addition of road salt—no engineer who examined the mall provided an “explicit warning” about what might happen if the leaks weren’t repaired. “None of the professionals appeared to have anticipated the severity of the corrosion.”

Related post: Elliot Lake mall survivor did not live to see inquiry report

Especially Robert Wood, a discredited engineer from nearby Sault Ste. Marie. The last professional to inspect the mall—just ten weeks before the roof fell down, as a prerequisite to a new financing arrangement for Nazarian—Wood saw nothing alarming. Despite “ongoing leakage” and “evidence of rusting” on many of the steel beams supporting the deck, he considered “the members still structurally sound.” He didn’t recommend a more comprehensive inspection, and the tone of his report was anything but urgent.

“His work provided unfounded assurances and gave the Mall owner a documented excuse to continue doing nothing,” Bélanger wrote. “His review was similar to that of a mechanic inspecting a car with a cracked engine block who pronounces the vehicle sound because of its good paint job.” (Of all the characters forever linked to the Elliot Lake collapse, Wood is the only one facing criminal charges, including two counts of criminal negligence causing death for allegedly “failing to recognize and report obvious and urgent structural integrity deficiencies.” His next court appearance is schedule for Friday.)

Bélanger’s conclusions cannot be used in court, whether against Wood, any other accused, or in connection with the multiple civil lawsuits stemming from the collapse. His mandate was to discover the truth, and suggest province-wide improvements. His 71 recommendations include:

• a requirement that all “large mercantile buildings” like the Algo Centre be maintained to a minimum standard. The Building Code dictates the construction of new structures, but there is no provincial law that ensures existing buildings are adequately maintained

• that buildings be regularly inspected by a qualified engineer, either when they are sold or “at a minimum frequency that is commensurate with the risk of harm”

• that information about whether buildings meet minimum public safety standards be available, in an “easily accessible” form, to the public

• that municipalities be required to keep a record of every property standards by-law complaint

• that Elliot Lake Retirement Living be more “open and transparent” and subject to Freedom of Information Laws

• that “there should be only one person in overall charge” of an emergency response

• that the province improve its so-called Incident Management System (IMS)

• that urban search and rescue teams be more adequately trained on the use of cranes as an option