Public inquiry makes 71 recommendations
The public inquiry into the fatal Algo Centre Mall collapse in Elliot Lake, Ont., in 2012 has released its final report, putting the blame on "human error."
Led by Justice Paul Belanger, the public inquiry delved into the roof collapse at the shopping mall that killed two women — Doloris Perizzolo and Lucie Aylwin.
In his report — which clocks in at 1,394 pages — Belanger noted that, despite the incontrovertible evidence pointing to severe rusting between a beam and column causing the roof to buckle, human error was unequivocally to blame.
"Many of those whose calling or occupation touched the mall displayed failings," Belanger said. "Some of these failings were minor, some were not: they ranged from apathy, neglect and indifference, through mediocrity, ineptitude and incompetence to outright greed, obfuscation and duplicity."
As part of his 71 recommendations, Belanger said there should be a province-wide requirement that buildings be maintained to a minimum standard to ensure public safety.
As such, all buildings should be properly inspected by qualified structural engineers when a building is sold and, at a minimum, at a frequency that is commensurate with the risk of harm from a failure to meet that standard.
"The standards should be enforceable by a simple and practical process which requires that the responsible public authorities are accountable for the decisions they make and the actions they take," Belanger said.
"Some of my recommendations are meant to provide more rapid provincial advisory assistance and support to smaller municipalities that do not have the financial means to afford the sophisticated systems that large upper-tier municipalities enjoy when faced with a local emergency."
Those charged with determining the safety standard of the buildings, including professional engineers, municipal officials and Ministry of Labour inspectors, should also be appropriately trained and certified, and their conclusions should be made readily and publicly available and accessible, he added.
The Elliot Lake mall focused the microscope on accountability when it comes to safety. Because there were many players involved — think designers, builders, owners, architects, engineers and provincial and municipal officials — the question has been asked: Where does the responsibility lie?
"One thing that is striking is that there are so many hands on this thing, so many fingerprints," said David Law, a partner at Gowlings labour and employment law firm in Ottawa.
"There is a lot of contributory negligence from a lot of different places," Law continued, likening the Elliot Lake inquiry to the Westray mine in Nova Scotia, where 26 miners were killed in a methane gas explosion in 1992, despite serious safety concerns raised by employees, union officials and government inspectors.
That prompted a public inquiry and Bill C-45, which amended the Criminal Code to establish criminal liability for organizations and those who act on their behalf.
"Private failures and public inspection failures and no follow-up — it was very difficult to prosecute anybody. It was difficult then to deal with these multi-causal (events). There was no one player that did it all," he explained. "Criminal law was amended for exactly that purpose."
The Algo Centre inquiry also discussed the merits of internal responsibility systems, something Law said everybody involved should consider.
"It needs more muscle or more energy," he said. "It’s a really powerful weapon, this notion of internal responsibility. Powerful because it empowers individuals and it also has a legal and moral accountability which is imposes on everybody to take care of each other. That’s ultimately a far more effective mechanism than waiting for the authorities."
Report will be noticed
Though the public inquiry is separate from ongoing criminal, regulatory or civil proceedings, Belanger’s report will not go unnoticed said Roger Oatley, the lawyer representing the Aylwin and Perizzolo families in a civil lawsuit against the City of Elliot Lake, Ontario’s Ministry of Labour, the engineering firm, the mall’s owners at the time and Elliot Lake’s mayor.
"It certainly creates atmosphere and any judge will be very aware of what Justice Belanger (said). It’s a very public condemnation of everyone who we have alleged is responsible," Oatley said.
As for the families affected by the tragedy, Belanger’s report provides some form of justice.
"What was very satisfying and comforting for the families was that blame net being spread to include everybody that had a hand in this failure," Oatley continued, adding, "We have a history of taking recommendations from inquests and public inquiries and putting them there on a shelf and leaving them there to gather dust…There is a tendency to go from one dramatic event like this to the next one the following day and leave tragedy like this behind because we can’t carry it all with us."
Belanger ended his report by urging the government to provide a snapshot of its progress of its implementation of his recommendations within one year.
