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Report of the Elliot Lake Commission of Inquiry Part Two: The Emergency Response and Inquiry Process The Honourable Paul R. Bélanger Commissioner
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  • Report of the Elliot LakeCommission of Inquiry

    Part Two:

    The Emergency Response and Inquiry Process

    The Honourable Paul R. BélangerCommissioner

  • Report of the Elliot LakeCommission of Inquiry

    Part Two:

    The Emergency Response and Inquiry Process

    The Honourable Paul R. BélangerCommissioner

  • The Report consists of three volumes: 1. The Events Leading to the Collapse of the Algo Centre Mall; 2. The Emergency Response and Inquiry Process; and 3. Executive Summary.

    Ontario Ministry of the Attorney General

    ISBN 978-1-4606-4558-1 (PDF)ISBN 978-1-4606-4556-7 (PDF – two volume set)ISBN 978-1-4606-4555-0 (Print)ISBN 978-1-4606-4553-6 (Print – two volume set)

    © Queen’s Printer for Ontario, 2014

    Disponible en français

    Recycled paper

  • This volume is dedicated to all first responders –

    those who put their life and health in harm’s way

    to help others. They are our heroes.

  • True heroism is remarkably sober, very undramatic. It is

    not the urge to surpass all others at whatever cost, but the

    urge to serve others at whatever cost.

    – Arthur Ashe

    http://www.brainyquote.com/quotes/quotes/a/arthurashe124531.htmlhttp://www.brainyquote.com/quotes/quotes/a/arthurashe124531.htmlhttp://www.brainyquote.com/quotes/quotes/a/arthurashe124531.html

  • The Emergency Response and Inquiry Process

    PART

    Chapter 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

    Chapter 2 Background of Responders and Emergency Management . . . . . . . . . . 5

    Chapter 3 First Responders and Deployments of Various Teams (Collapse to 11 p.m. on June 23) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

    Chapter 4 Rescue Efforts (12:30 a.m. on June 24 to 9:30 a.m. on June 25) . . . .109

    Chapter 5 Calling off the Rescue: Now Recovery (9:30 a.m. to 7:30 p.m. on June 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163

    Chapter 6 Political Intervention and Resumption of the Rescue / Recovery (7:30 p.m. on June 25 to 6:00 a.m. on June 27) . . . . . . . . . . . . . . . . . . .207

    Chapter 7 Victim Recovery on June 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .287

    Chapter 8 The Victims: Cause and Time of Death . . . . . . . . . . . . . . . . . . . . . . . . . . .297

    Chapter 9 After-Action Reports, Debriefings, and Lessons Learned . . . . . . . . . .323

    Chapter 10 General Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .369

    Chapter 11 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .385

    Inquiry Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .435

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Processvi

    APPENDICES

    PART TWO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475Appendix A – Key people in the emergency response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478

    Appendix B – Chronology of the emergency response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482

    Appendix C – Schedule of witnesses – Part Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485

    Appendix D – Policy roundtables – Part Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487

    Appendix E – List of appearances for Participants with standing and witnesses – Part Two . . . . . . . 495

    INQUIRY PROCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496Appendix F – Order in Council . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496

    Appendix G – Order in Council extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499

    Appendix H – Commission personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500

    Appendix I – Inquiry statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502

    Appendix J – Letters and statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503

    Appendix K – Commission Rules and Procedural Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521

    Appendix L – List of overview reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544

    Appendix M – Rulings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545

    Appendix N – Example of summons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624

    Appendix O – Undertaking re confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627

    Appendix P – Certificate of production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633

    Appendix Q – Example of Section 17 Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635

    Appendix R – Letter to Attorney General requesting extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637

    GLOSSARY, ABBREVIATIONS AND ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643

    Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647

  • CHAPTER

    Introduction

    Before, you are wise; after, you are wise. In between you are otherwise.

    David Zindell, The Broken God

    uIt is easy to be wise after the event.

    Arthur Conan Doyle, The Complete Sherlock Holmes

    u

    This second volume of the Report examines the emergency response in the aftermath of the Algo Mall collapse. Unlike Part One, which reviewed a span of more than 30 years, these chapters set out a story of less than a week in duration. Compared to the behaviour of many of the players whose three-decade-long involvement in the Mall’s well-being may be questioned and criticized, the emergency response cannot be faulted for lack of praiseworthy intentions, engagement, determination, and, not infrequently, bravery and courage.

    During this response, a congruence of errors – some minor, some more important – led to a rescue effort that was no model of perfection. As a result, questions will long persist about the possibility that Lucie Aylwin could have been rescued. As I pointed out elsewhere in this Report, we learn best through experience. A critical analysis of that experience is crucial to identify error or to confirm success. The lessons learned can then be transmitted to others – to improve future responses.

    In this part of the Report, I will attempt a detailed narrative of the events that followed the collapse on June 23, 2012. Inevitably, given the varying quality of observation in times of stress, there will be different interpretations of discrete events. That is the nature of human memory, particularly when it is unaided by contemporaneous recording and prompt, careful debriefing.

    Doloris Perizzolo’s death was unquestionably and mercifully quick. But the extent to which miscues, miscommunications, and mistakes prevented the rescue of Lucie Aylwin is a difficult question. Some medical evidence supports the proposition that death came quickly. However, living for a period of time was not inconsistent with any of the medical indicia discussed by one medical witness. Tantalizing signs may lead one to conclude that it is probable (though by no means certain) that she lived for some time after the initial collapse and might have been found alive had the rescue effort been executed more rapidly and effectively. By 5 a.m. on June 25, however, it is probable (but again, not conclusively certain) that she had died. We will never confidently know the answer to these troubling concerns.

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process2

    The hearings for this part of the Inquiry lasted 36 days, and I heard 52 witnesses. Many of those witnesses, family members and loved ones in particular, recounted being desperate for information and decried the quality and manner in which it was communicated to them.

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

    I heard from the province’s premier, Dalton McGuinty, whose concern and support throughout the ordeal was genuine and constant. He gave hope and renewed determination when the rescue effort had ebbed to its lowest point. I also heard from the region’s MPP (Algoma-Manitoulin), Michael Mantha, whose presence, assistance, and moral support to the community was unflagging and tireless and who represented the best of what is expected of our elected representatives.

    My analysis of the facts underpinning this narrative follows, along with my recommendations to improve emergency responses. I also describe the process of this Inquiry and make suggestions for future such commissions. Improvement is achieved gradually and incrementally and builds on the shoulders of others. Perfection is an impossibly elusive goal – one that is virtually never achieved. As Vince Lombardi is quoted as saying, “Perfection is not attainable, but if we chase perfection we can catch excellence.”

    I embark on that analysis with diffidence and some significant reservation, because I am aware of this Commission’s lack of expertise in emergency rescue operations. The training and practical experience of many of the first responders was decades long. My learning period, as well as that of Commission counsel, has been brief and purely theoretical.

    I am also conscious, as I previously commented, of the perils of judging events in hindsight. Choosing the right path through the thicket is easy when you can look down on it from a high vantage point, but not when you are enmeshed in it on perilous ground. Although hindsight is a dangerous tool in assessing past conduct, it is, however, essential in crafting recommendations. Many witnesses, experts in their own right, commented in their testimony on what they and others should have done differently. Their views are important and valuable, and, in crafting my recommendations, I gave a lot of weight to their opinions.

    Unfortunately, the rescue effort that was mounted after the collapse did not save any lives. The measure of a response’s effectiveness cannot simply be gauged by whether lives were saved as a result of it. That measure is far too simplistic. An inept rescue may save lives by pure luck or cause the further loss of life; by contrast, circumstances may defeat the best-executed plans.

    One constant, however, stands out above all the others: an effective and efficient first-response system is essential to the health, safety, and security of Ontario’s citizens. With the integration of Ontario’s first-response organizations with those of other provinces, this system is now also essential for all Canadians. Any diminution in the financial contributions of governments – municipal, provincial, or federal – is unwarranted and dangerous. Quite the opposite: those contributions should be enhanced.

    The evidence I heard in the second phase of the Inquiry provided me with a view into the world of emergency management and response. This world, I have come to learn, is heavily populated by totally committed, selfless, and courageous men and women. That said, it still remains that few human endeavours cannot be improved upon. Any criticism I make about any aspect of the response to the Algo Mall collapse should not be interpreted as a lessening of my esteem and admiration for our first responders.

  • Chapter 1 Introduction 3

    Stated in their simplest terms, my principal conclusions for this part of the Inquiry are as follows:

    • Doloris Perizzolo’s death was nearly instantaneous after the collapse, but it is probable (though by no means certain) that Lucie Aylwin survived under the rubble for a period of up to 39 hours. It is unlikely that she survived beyond 5 a.m. on June 25. There exists a possibility she might have been rescued, but we will never know for sure.

    • Local authorities acted promptly and appropriately in the immediate aftermath of the collapse. They assisted in the evacuation of the Mall, helped the injured, and secured the site by shutting off utilities and establishing site control. Provincial authorities were rapidly informed, and assistance was summoned after the declaration of a municipal emergency.

    • HUSAR/TF3 could have deployed more rapidly. UCRT’s deployment speed was exceptional.• Both HUSAR/TF3 and UCRT deployment numbers were not optimal, particularly at the command level.• The lack of an incident action plan was detrimental to the rescue effort.• The Incident Management System was improperly applied: no one understood or respected its mandated

    command structure.

    • The relationship between HUSAR/TF3 and UCRT was occasionally problematic.• There was a failure to resort to crane / rigging operations early and consistently – they were relegated to a

    solution of last resort.

    • Record-keeping and note-taking were deficient.• Communications among responders, with victims’ families, and with the media and the general

    public were poor.

    • Although it was proper to remove the rescuers from the building because of the dangerous state of the rubble pile, the rescue was called off, instead of being paused while alternatives were considered.

    • The services offered by Ontario Mine Rescue should not have been ignored.• The role of Ministry of Labour officials was widely misunderstood.• After-action debriefings and many after-action reports were either non-existent or poorly done.• Provincial legislation, including the Coroners Act, does not allow an official to demolish a building to

    retrieve a body.

    • The premier of Ontario, his office, and other provincial authorities acted with leadership, genuine compassion, and assistance when hope seemed lost.

    • Ontario’s urban search and rescue system needs a careful re-examination to provide better overall coverage and quality of service.

    One final comment: I was informed during the hearings that Fire Chief Paul Officer’s nomination of certain of his Elliot Lake firefighters for the Ontario Medal for Firefighter Bravery Award have been put on hold until this Commission has completed its work. These awards should wait no longer. They are richly deserved.

  • CHAPTER

    Background of Responders and Emergency Management

    Emergency management in Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Graduated problem solving and emergency response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

    The role of the municipality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

    The municipal emergency management program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

    Municipal emergency control groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

    Municipal emergency management program coordinator and committee . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

    Declaration of an emergency by the municipality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

    Community emergency operations centres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

    Mutual aid system and municipal capacity expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

    Volunteers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

    The role of the province . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

    Premier of Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

    Lieutenant governor in council . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

    Ministry of Community Safety and Correctional Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

    Provincial Emergency Response Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

    The Provincial Emergency Response Plan for Building Structural Collapse 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . .15

    Provincial Emergency Operations Centre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

    Emergency Management Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

    Office of the Fire Marshal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

    Mutual assistance between provinces and territories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

    The role of the federal government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

    Incident Management System: the system as it is intended to work . . . . . . . . . . . . . . . 19Background and purpose of the Incident Management System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

    The Incident Management System is not mandatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

    Incident Management System organizational structure and management functions . . . . . . . . . . . .20

    Command . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

    The incident commander . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

    Operations, planning, logistics, and finance and administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process6

    The incident action plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

    Planning cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

    Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

    Overview of key players in the Elliot Lake response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Elliot Lake Fire Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

    Training and equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

    Tactical priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

    City of Elliot Lake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

    Emergency response plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

    Community Control Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

    Responsibilities of some of the key players of the Community Control Group . . . . . . . . . . . . . . . . . . . . . . . . . .28

    Emergency Operations Centre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

    East Algoma OPP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

    City of Toronto Heavy Urban Search and Rescue team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

    Classification of Urban Search and Rescue teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

    History of the Toronto HUSAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

    Composition of the Toronto HUSAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

    Training standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

    Team member training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

    Mobilization of HUSAR/TF3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

    Ontario Provincial Police . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

    Composition of UCRT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

    Training of UCRT members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

    Deployment of UCRT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

    The Ministry of Labour in an emergency response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

    Why the Ministry of Labour may get involved in an emergency response . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

    The applicability of the Occupational Health and Safety Act at the scene of an emergency response . . . . . .36

    The expected roles of Ministry of Labour personnel at an emergency response . . . . . . . . . . . . . . . . . . . . . . . .36

    Ontario Mine Rescue – a successful emergency response organization . . . . . . . . . . . . . . . . . . . . . . . . . .36

    Safety of responders is the first priority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

    Extensive training and equipment, similar to that of HUSAR/TF3 and UCRT . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

    Response time: on site within 30 minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

    Chain of command . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38One official in charge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

    Support and information from the mine rescue officer and the emergency control group . . . . . . . . . . . . . . .39Briefing officer as the liaison between the control group and the operations team . . . . . . . . . . . . . . . . . .39Team captain in charge of operations team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

  • Chapter 2 Background of Responders and Emergency Management 7

    Planning is absolutely critical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

    Briefing team members: in writing, with opportunity for questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

    Written logs and reports required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

    Debriefings: essential and useful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

    OMR’s experience: extensive and useful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

    Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process8

    To understand the response to the collapse of the Algo Mall, it is necessary to first review the way the province, the municipalities, and other responders are organized to deal with emergencies of this type. Accordingly, I will provide background information in this chapter on

    • emergency management in Ontario;• the Incident Management System;• organizations that participated directly in the rescue; and• organizations that provided support and advice.

    The description of the emergency management structure in Ontario that follows reflects the one in place at the time of the Mall’s collapse. Although there have been some administrative changes since then, it is my understanding that the framework remains essentially the same.

    Emergency management in OntarioThe primary provincial legislation dealing with emergency management is the Emergency Management and Civil Protection Act (EMCPA). It reflects the five pillars of emergency management:

    • mitigation• prevention• preparation• response• recovery1

    The Act defines “emergency” as “a situation or an impending situation that constitutes a danger of major proportions that could result in serious harm to persons or substantial damage to property and that is caused by the forces of nature, a disease or other health risk, an accident or an act whether intentional or otherwise.”2

    Graduated problem solving and emergency response

    The first response is almost always local: it begins with the individual or the family and evolves from there. The province’s emergency response regime is designed to reflect this process. The Ontario government’s Provincial Emergency Response Plan expects individuals and families to be able to respond to an emergency and be self-sufficient for the first 72 hours.3 This approach is described as “graduated problem-solving.”4 It is “bottom up” and meant to keep emergency response as localized as possible while ensuring that all the necessary resources are available in a timely fashion.

    Where an emergency escalates beyond the capacities of the individual or family, the expectation is that the local community or municipality will take over. Communities assist as a matter of routine through emergency responders such as police, fire, and emergency medical services.5

    Where an emergency escalates beyond the capacities of the individual or family, the expectation is that the local community or municipality will take over. Communities assist as a matter of routine through emergency responders such as police, fire, and emergency medical services.

  • Chapter 2 Background of Responders and Emergency Management 9

    Where the emergency in question overwhelms the capacities of the local municipality or community and its first responders, the next step is to seek mutual aid or assistance from neighbouring services, municipalities, and communities or from the local county or region. Mutual aid programs are unique to fire services and are required under the Fire Protection and Prevention Act.6 Municipalities can also form agreements with neighbouring communities to provide assistance to each other in times of need for matters that are not related to fires. These agreements are called “mutual assistance.”7

    Where the mutual aid or assistance system will not suffice, the local community can look to the Ontario government for further support. The Province of Ontario has emergency resources and expertise which may be used to deal with emergency response needs that are beyond the capabilities of local communities.8 Indeed, the local community can ask for provincial assistance at any time, even where the mutual aid or mutual assistance systems are sufficient.9

    Finally, and depending on the nature and severity of the incident in question, the province may require the assistance of the federal government or even international assistance. The nature of the emergency may also be such that jurisdiction falls automatically to the federal government.10

    The provision of assistance from one level of government to another may require a declaration of emergency, unless normal powers and procedures will suffice. A declaration of emergency, in keeping with the graduated approach, should be at the lowest level of jurisdiction. As such, it should seldom be necessary to declare a provincial or federal emergency, even though resources from these jurisdictions will frequently be provided in support of an emergency declared by a municipality or a First Nation.11

    The role of the municipality

    In accordance with the graduated problem-solving model, emergency response in Ontario is to be managed at the lowest level possible – at the community or municipality level. As such, Ontario municipalities are subject to a series of legislated responsibilities related to emergency response, chiefly pursuant to the Emergency Management and Civil Protection Act. The Act also sets out powers that may be exercised by the municipality and the province during an actual emergency, but without expressly defining the relationship between the province and the municipalities.12

    All municipalities must have in place the following structure for emergency response. It includes the creation of community emergency management programs, emergency plans, control groups, emergency operation centres, and mutual aid arrangements.

    The municipal emergency management programEvery municipality in Ontario is required by law to develop and implement an emergency management program and to pass a by-law specifically adopting the program. It must include an emergency response plan, training programs, and exercise sessions for municipal employees and others as well as the procedures to be followed in emergency response and recovery activities. It must also provide for public education on the risks to public safety and on how the public can best be prepared for emergencies.13 The training programs and exercises for municipal employees and others allow for the inclusion of non-governmental organizations that are expected to play a role in the emergency response plan – for example, the Salvation Army or the Red Cross.14

    The Province of Ontario has emergency resources and expertise which may be used to deal with emergency response needs that are beyond the capabilities of local communities.

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process10

    Dan Hefkey holds the position of commissioner for community safety, as he did when he appeared at the Inquiry. The fire marshal and the chief of Emergency Management Ontario both report directly to him. He explained that the Emergency Management and Civil Protection Act does not contain any provision dealing with non-compliance with the Act.15 Although the Act requires municipalities to have an emergency management program that includes an emergency plan, there is no statutory penalty for those that do not comply. He testified, however, that there is almost complete compliance. At any time, on average, only four to eight municipalities in the province are deficient in some aspect of the requirements.16

    Municipalities must conduct annual reviews of their emergency management programs and make recommendations to the local council about any revisions that are required.17 The emergency management program must also assess various hazards and risks to public safety in the community which could give rise to emergencies and, in addition, identify facilities and infrastructure that are at risk of being affected by emergencies and for which the municipality is responsible.18

    This process of hazard identification and risk assessment is expected to shape the plan. It identifies what the hazards are within the municipality and makes a judgment on the likelihood of an event happening as well as its consequences in terms of lives and property damage. Emergency Management Ontario, a branch of the Ministry of Community Safety and Correctional Services which is responsible for developing, promoting, and maintaining emergency programs, expects that each municipality will regularly revisit this assessment, simply because changes in circumstances require changes to emergency plans. Municipalities are not required to provide Emergency Management Ontario with a copy of their hazard identification and risk assessment.19

    The emergency response plan sets out the procedures on how each particular municipality will respond to an emergency.20 In addition, it lays out the responsibilities of municipal employees in carrying out the plan.*

    Municipal emergency control groupsMunicipalities are also required by regulation to have in place a municipal emergency control group – to direct the municipality’s response in an emergency, including the implementation of the emergency response plan.21 This group is more commonly referred to as the Community Control Group (CCG).22

    Mr. Hefkey explained that the role of the CCG is to act in support of those who are actually dealing with the emergency. The group does not direct the responders – its concern is generally broader than the emergency incident itself and includes the effects and consequences of the emergency on the community.23 The group must be composed of officials or employees of the municipality appointed by the municipal council, and it may include members of the City Council itself. All members of the group must complete annual training as required by the chief of Emergency Management Ontario.24

    According to Mr. Hefkey, a CCG would typically include the mayor, deputy mayor, chief administrative officer, and the heads of the municipal departments such as public works, police, fire, emergency management services, public health, and social services.25 When an emergency occurs, the municipality’s emergency control group will usually convene to activate the emergency plan and, using that plan, access local resources to support emergency operations.26

    * Emergency Management and Civil Protection Act, O Reg 380/04, s 15.

    Further instruction on minimum standards for municipal (and provincial) emergency management programs is found in Ontario Regulation 380/04, created to support the requirements in the Emergency Management and Civil Protection Act.

  • Chapter 2 Background of Responders and Emergency Management 11

    An incident commander may be appointed by the CCG to manage operations at the site of the emergency event. This commander is usually a senior officer from one of the local emergency services.27 That said, an incident command structure will likely already have been in place at the onset of the emergency response, set up by the emergency first responders even before the declaration of emergency by the community.

    Municipal emergency management program coordinator and committeeThe municipality must also designate an employee of the municipality or a member of the city council as its emergency management program coordinator. In addition, it must have in place an Emergency Management Program Committee (EMPC).28

    The emergency management program coordinator manages the development and implementation of the municipality’s emergency management program within the municipality and, to the extent possible, coordinates it with that of other municipalities, ministries of the Ontario government, and organizations outside government that are involved in emergency management.29 The EMPC advises the municipal council on the development and implementation of the municipality’s emergency management program. It also conducts an annual review of the program and makes recommendations to council for its revisions resulting from an updated hazard identification and risk assessment.30

    Declaration of an emergency by the municipalitySection 4 of the Emergency Management and Civil Protection Act provides that the head of the council in a municipality may declare that an emergency exists in either the whole or a part of the municipality. The council head will then take such action and make such orders as he or she considers necessary, and which are not contrary to law, to implement the municipality’s emergency plan and to protect both the property and the health, safety, and welfare of the residents in the emergency area.31 The declaration can be made whenever the head of council considers that an emergency exists. There is no condition precedent, or particular event, that must occur before the exercise of this power.32 Of course, municipalities can (and do) take steps to respond to an emergency without making a formal declaration.33

    If a municipality declares an emergency, it must notify the province.34 On average, every year some 23 municipal emergency declarations are made in Ontario. However, no provincial emergency has been declared since the Act came into force in 2006.35

    Community emergency operations centresDuring an emergency, municipalities are required to have a community Emergency Operations Centre (EOC) in place, operating under the direction of the municipal emergency control group.36 From there the group manages the emergency. When an emergency situation arises, local municipalities are expected to follow their emergency plans and, where necessary, activate their EOC in order to coordinate local emergency response efforts.37

    The municipality must appoint an emergency information officer to act as its primary media and public contact during an emergency.38 That does not mean, however, that the emergency information officer has to be the spokesperson for the municipal emergency control group. It is expected that the designation of a spokesperson will be addressed within the emergency response plan.39

    If a municipality declares an emergency, it must notify the province. On average, every year some 23 municipal emergency declarations are made in Ontario.

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process12

    The municipality should have appropriate technological and telecommunications systems in place to ensure effective communication in an emergency. It must also have a procedure to inform the Provincial Emergency Operations Centre (PEOC) of an emergency and of possible requirements for assistance.40

    Mutual aid system and municipal capacity expectationsWithin the gradual problem-solving approach, a municipality can rely on provincial mutual aid systems for fire departments when an emergency exceeds its capacity. The mutual aid system is established under the authority of the Fire Protection and Prevention Act, 1997, and administered by the Office of the Fire Marshal.

    Fire coordinators, appointed by the Office of the Fire Marshal, are responsible for establishing and maintaining a mutual aid plan through which the various fire departments serving a designated area agree to assist each

    other in the event of an emergency.41 Fire coordinators submit these mutual aid plans to the fire marshal for review and approval, and the Ministry of Community Safety and Correctional Services maintains a repository of all Ontario mutual aid plans for use in emergency situations.42

    The mutual aid can take the form of providing personnel and/or equipment to deal with the emergency. It also includes the provision of personnel from the neighbouring fire service to tend to the ongoing needs for fire protection services in the host community while the host fire service deals with the emergency.43

    The Fire Protection and Prevention Act, 1997, requires that municipalities provide fire protection services to their communities as necessary and in accordance with their needs and circumstances. Municipalities are not required to possess more extensive capacities such as urban search and rescue teams.44

    VolunteersOntario’s emergency response plan briefly addresses the role of volunteers and supporting organizations in an emergency response. Municipalities may require personnel, services, equipment, and/or material from non-profit or voluntary organizations and should include these types of considerations in their emergency response planning processes.45

    The Provincial Emergency Response Plan makes the following cautionary comment about the use of volunteers during an emergency:

    Municipalities and provincial ministries should carefully consider their need for, and the capabilities of, unaffiliated volunteer assistance during an emergency and systematically register all those who participate in the emergency response.46

    The Fire Protection and Prevention Act, 1997, requires that municipalities provide fire protection services to their communities as necessary and in accordance with their needs and circumstances. Municipalities are not required to possess more extensive capacities such as urban search and rescue teams.

  • Chapter 2 Background of Responders and Emergency Management 13

    The role of the province

    Where the municipal and local structure is insufficient to deal with an emergency, the municipality can look to the province for further resources and assistance.

    The Emergency Management and Civil Protection Act contains organizational structures, roles, and responsibilities for all ministries that are analogous to those required of municipalities. For example, ministries must have a ministry emergency management coordinator and a ministry action group. The group’s role and responsibilities are the same as those of a municipality’s emergency control group.47

    Premier of OntarioThe Emergency Management and Civil Protection Act provides that the premier of Ontario may, if in his or her opinion the urgency of the situation requires that an order be made immediately, declare that an emergency exists throughout Ontario or in any part thereof.48 If the emergency area or any part of it is within the jurisdiction of a municipality, the premier may, if deemed necessary, direct and control the administration, facilities, and equipment of the municipality in the emergency area49 and may direct other municipalities to render assistance.50

    The premier and the lieutenant governor in council may provide overall direction to the management of an emergency response when a provincial emergency has been declared, but not where the province has merely provided provincial resources or assistance to a municipality.51

    Lieutenant governor in councilPowers to declare an emergency are also conferred on the lieutenant governor in council. While the premier may declare a provincial emergency only if the urgency of the situation requires that such a declaration be made immediately, the lieutenant governor in council may do so if the resources normally available to the government are considered insufficient to respond adequately to the crisis.52

    Ministry of Community Safety and Correctional ServicesThe key ministry within the Government of Ontario for emergency response is the Ministry of Community Safety and Correctional Services. It houses important players in the emergency response field, including Emergency Management Ontario and the Office of the Fire Marshal. In August 2013, these two divisions were merged to form the Office of the Fire Marshal and Emergency Management. According to a government press release, “[t]his new, integrated organization will strengthen the co-ordination and delivery of community safety programs, without impacting front-line services.”53 Figure 2.2.1 sets out an organizational chart for the Community Safety side of the ministry as it existed on June 1, 2012.

    If several ministries require a coordinated effort, the Ministry of Community Safety and Correctional Services will coordinate the joint response, normally through the Provincial Emergency Operations Centre (PEOC) described below. In addition, the ministry has the primary responsibility for managing the consequences of any structural collapse of buildings in Ontario.54

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process14

    Figure 2.2.1 Organizational chart of the community safety side of Ministry of Community Safety and Correctional Services

    Source Exhibit 7886

    Advisory and Adjudicative Agencies, Boards & Commissions

    Const. Joe MacDonald Public Safety Officers Survivor’s Scholarship

    Fund – Chair

    Fire Safety Commission – Chair

    Animal Care Review Board – Chair

    Fire Marshal’s Public Fire Safety Council – Chair

    Ontario Police Arbitration Commission – Chair

    Ontario Civilan Police Commission – Chair

    Ontario Parole Board – Chair

    Death Investigation Oversight Council

    Minister of Community Safety and Correctional

    Services

    Deputy Minister Community Safety

    Executive Assistant

    Project Management

    A. Director

    Operational ServicesDirector

    Prov. Command Field Operations

    Dep. Comm.

    Prov. Command Investigations/

    Organized CrimeDep. Comm.

    Prov. CommandTraffic Safety &

    Ops. SupportDep. Comm.

    Commissioner, Community Safety

    Commissioner

    Office of the Chief Coroner

    Chief Coroner

    Ontario Forensic Pathology Service

    Chief Forensic Pathologist

    Office of the Fire Marshal

    Fire Marshal

    Emergency Management Ontario

    ADM/Chief

    External RelationsDirector

    Private Security & Investigative Services

    Director

    Ontario Police CollegeA. Director

    Centre of Forensic SciencesDirector

    Criminal Intelligence Service Ontario

    Director

    Ontario Provincial Police

    Commissioner

    Public SafetyADM

    Deputy Fire MarshalA. Dep. Fire Marshal

    Administration and Business Services

    A. Director

    Support ProgramsDirector

    Bureau Commander Business &

    Financial PlanningDirector

    Bureau CommanderCareer

    DevelopmentChief Superintendent

    Prov. CommandCorporate Services

    Prov. Comm.

  • Chapter 2 Background of Responders and Emergency Management 15

    Provincial Emergency Response PlanThe Ontario government is responsible for protecting public health and safety, property, and the environment within its borders. It has primary responsibility for managing the consequences of an emergency, such as a building’s structural collapse or a chemical spill, once the community or the municipality has exceeded its resources, and for implementing mutual aid agreements. The Provincial Emergency Response Plan, developed pursuant to the Emergency Management and Civil Protection Act, is used to coordinate the overall provincial emergency response. It outlines how Emergency Management Ontario and the ministries respond to widespread or large-scale emergencies.55

    The stated purpose of the Provincial Emergency Response Plan is to “establish a framework for a systematic, coordinated and effective emergency response by the Province of Ontario to safeguard the health, safety, welfare and property of its citizens, as well as to protect the environment and economy of the area affected by an emergency, excluding nuclear emergencies.”56 The Act requires the lieutenant governor in council to formulate a distinct emergency plan respecting emergencies arising in connection with nuclear facilities.57

    The Provincial Emergency Response Plan for Building Structural Collapse 2010All ministries of the provincial government are required to develop an emergency management program that includes an emergency plan. All ministers must develop an emergency plan for any emergency that affects the continuity of operations and services in their respective ministries. In addition, 13 ministers have been given the responsibility to develop emergency plans with respect to specific types of emergencies set out in Order in Council 1157-2009. These plans, developed by the ministries, fit within the overall Provincial Emergency Response Plan.58 The Ministry of Community Safety and Correctional Services was given responsibility to develop the emergency response plan for the structural collapse of buildings.59

    The Provincial Emergency Response Plan for Building Structural Collapse 2010 recognizes that the primary responsibility for managing an emergency resulting from a building’s structural collapse rests with the community and with local resources. The plan addresses how the province is intended to respond to such an emergency. It does not require the declaration of a provincial emergency to become operational. In fact, it does not specifically require the declaration of a municipal emergency. Since the community has responsibility for managing the emergency, the province has a supporting role by providing assistance. This assistance may take the form of simply providing advice, but it may also expand to the provision of personnel, equipment, and other resources to assist the community in dealing with the cause of the emergency.60

    The province, through the Office of the Fire Marshal, has access to a number of specialized teams that can assist in the response to a building collapse – urban search and rescue teams as well as chemical, biological, radiological, nuclear, and explosive teams. Nearly all these teams are operated by municipalities. The province has entered into a memorandum of understanding with all the municipalities which allows it to deploy these teams under specified circumstances.61 When provincial resources are sent to support a local municipality, they come under the operational control of the local incident commander in accordance with the provincial Incident Management System (IMS) doctrine described later.62

    In the event of a building’s structural collapse, the province has access to two urban search and rescue teams. The first, known as Canada Task Force 3 (TF3), or Toronto HUSAR, is a heavy-level urban search and rescue team operated by the City of Toronto.63 The Ontario Provincial Police (OPP) has an urban search and rescue team as well as a chemical, biological, radiological, nuclear, and explosive (CBRNE) team that is collectively known as UCRT.64 The UCRT team is available to the province on request as long as it is not otherwise occupied.65

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process16

    The OPP team is located in Bolton, Ontario, a few kilometres north of Toronto. Therefore, the province’s entire inventory of urban search and rescue assets is located in the Greater Toronto Area. The cities of Ottawa and Thunder Bay each operate their own medium-level search and rescue team.* The province has not signed a memorandum of understanding with either city, and, therefore, these teams are not deployable by the province.66

    Municipalities in Ontario operate nine CBRNE teams in all. The cities of Toronto, Ottawa, and Windsor have level 3 teams,† and the cities of Sault Ste. Marie, Thunder Bay, Cornwall, Peterborough, North Bay, and Kitchener / Cambridge / Waterloo have level 2 teams.67

    The cost of deployment by the province of any of the specialized teams, whether urban search and rescue or CBRNE, is borne by the province, not the municipality.68

    Provincial Emergency Operations CentreThe Provincial Emergency Operations Centre (PEOC) is located within the Ministry of Community Safety and Correctional Services in Toronto and is managed by Emergency Management Ontario. It is staffed at all times.69 Ontario’s Provincial Emergency Response Plan calls for potential or actual emergencies to be reported promptly to the centre. These reports may come from many sources, including municipalities or other ministries.70

    Ontario has provided a description of how Emergency Management Ontario (EMO) and the PEOC respond to an emergency declaration:

    When a Head of Council declares an emergency, the province must be notified. Typically a municipality will notify the province via a telephone call/fax to the 24/7 Duty Office in the Provincial Emergency Operations Centre (PEOC).

    When the PEOC Duty Officer receives a declaration of an emergency, a series of questions are posed to the person notifying the PEOC to verify contact information, situational details and to determine if any provincial assistance is being requested by the municipality. If provincial assistance is required, the PEOC Duty Officer will notify the applicable provincial officials regarding the request and the circumstances thereof.

    During normal business hours, Emergency Management Ontario staff in the PEOC and EMO’s Operations Section will lead EMO’s response to the emergency declaration. This will include creating an Emergency Information Notification (EIN) [replaced after May 2013 by an Incident Briefing Form], disseminating this document to designated provincial and ministry representatives, contacting ministry representatives who may be able to support response operations and scheduling a teleconference with impacted municipalities, ministry officials and, as necessary[,] federal departments and agencies.

    Outside of normal business hours, this work follows a similar path, but is truncated due to fewer staff being readily available. The PEOC Duty Officer is in regular contact with an EMO Duty Operations Chief (DOC) and Duty Commander (DC) and these three officials would work collaboratively to create the necessary EINs and notify provincial staff of the emerging situation.71

    When a municipality declares an emergency, all the various ministry emergency management coordinators are notified by the PEOC. A ministry may choose to send staff to the event if it has implications for its mandate.72

    * Urban search and rescue teams are classified as heavy, medium, or light, based in part on their capacity to operate. These distinctions will be explained in greater detail later on in this Report.

    † These levels refer to National Fire Protection Standard 472, which covers minimum competencies of persons responding to incidents involving hazardous materials. Level 3 refers to the technician level, whereas level 2 to operational level. Further details are explained later in the Report.

  • Chapter 2 Background of Responders and Emergency Management 17

    Emergency Management OntarioEmergency Management Ontario (EMO) is the organization within the Ministry of Community Safety and Correctional Services with the responsibility to monitor, coordinate, and assist with the promotion, development, implementation, and maintenance of emergency management programs in Ontario at both the municipal and the provincial ministry levels. This responsibility includes the coordination of these programs with the federal government. In fulfilling this special coordination role, EMO coordinates provincial emergency response through the PEOC when required and provides advice and assistance to communities and ministries in all areas of emergency management. This assistance includes regular contact with municipalities to assess their compliance with the requirements of their particular emergency management program.73

    EMO also maintains the Provincial Emergency Response Plan and the Provincial Nuclear Emergency Response Plan. The Provincial Emergency Response Plan must be fully reviewed, amended, and brought forward for ministerial approval at least once every four years.74 As discussed, EMO has also developed an emergency response plan specifically for structural collapses – the Provincial Emergency Response Plan for Building Structural Collapse 2010.75

    The Emergency Management and Civil Protection Act provides for the appointment of a chief of EMO, who, under the direction of the minister of community safety and correctional services, “is to be responsible for monitoring, coordinating and assisting in the development and implementation of municipal and provincial emergency management programs throughout Ontario.”76

    EMO has field officers throughout the province who live and work in the geographical area they serve. They can offer subject matter expertise, support, and advice to the community emergency management program coordinators located within their respective areas.77

    During an emergency, whether declared or not, an EMO representative may be deployed to a community to act as a liaison and to provide emergency management advice to council and senior staff. Other provincial staff may be deployed to provide additional advice, assistance, and services, under the coordination of EMO.78 Such deployed staff are referred to by the Government of Ontario as the EMO Provincial Emergency Response Team (PERT), primarily made up of EMO field officers.79

    EMO also has training available for all emergency management personnel in Ontario (including provincial and local emergency management personnel and first responders). Some of the courses available are as follows:80

    • Basic Emergency Management Course, which covers all the basic principles of emergency management.• Basic Emergency Management Instructor Course, which enables the candidate to be a certified basic

    emergency management instructor.

    • Community Emergency Management Coordinators Course, which provides specific training to enable the designated community emergency management coordinator to administer the municipality’s emergency management program.

    • Incident Management System (IMS) courses, which provide a progressive learning system to train emergency responders in how to perform specific emergency management functions on a coordinated basis during emergency operations. Five IMS courses were available in Ontario at the time of the Commission hearings.

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process18

    Office of the Fire MarshalThe Office of the Fire Marshal, along with the Ontario Provincial Police and Emergency Management Ontario field officers, may be one of the first provincial-level actors involved with emergency response at the local level, either monitoring or responding directly to the emergency.

    As mentioned earlier, the fire marshal is responsible for appointing “fire coordinators” for designated areas. These, in turn, establish and maintain mutual aid plans under which the fire departments that serve a designated area agree to assist each other in the event of an emergency and to perform other duties the fire marshal may assign.81

    In addition to overseeing the implementation of mutual aid plans, the Office of the Fire Marshal has an Emergency Preparedness and Response Unit. This unit is designed to deal with situations where individual fire departments need to respond to incidents beyond their capabilities and beyond the capabilities of the mutual aid system.82

    The unit responds on a full-time (24/7) basis to requests for assistance from municipal fire departments, including heavy urban search and rescue. Personnel in the Office of the Fire Marshal assess the need of a particular situation to ensure that the appropriate resource is deployed. In addition, program specialists from the unit are available to be deployed principally for liaison and for supporting the operations.83

    Carol-Lynn Chambers was the operations manager of the Emergency Preparedness and Response Unit at the Office of the Fire Marshal at the time of the collapse. She explained that, typically, a local fire chief would contact the Provincial Emergency Operations Centre, which in turn would contact the operations manager. She would then get the phone number of the fire chief and call the chief directly to discuss what was needed, activate the appropriate response, and, if desirable, allocate any of her staff. She would then advise the Provincial Emergency Operations Centre of the appropriate response, which in turn would advise the commissioner of community safety.84

    Other resources available through the Office of the Fire Marshal include

    • advice, technical assistance, and equipment for hazardous material emergencies; and• support for other major emergencies, in various forms, including portable lighting and generator support,

    radio / communications equipment, and incident documentation.85

    Finally, the Office of the Fire Marshal can be involved with the operation and deployment of the Toronto Heavy Urban Search and Rescue team, as discussed further below.86

    Mutual assistance between provinces and territoriesThere are also mutual assistance agreements between the provinces and territories in Canada. A Memorandum of Understanding on Jurisdictional Emergency Management Assistance has been approved by all provinces and territorial ministers responsible for emergency management. This memorandum provides the framework within which provinces and territories would provide support to other Canadian jurisdictions.87

    Heavy urban search and rescue teams are located in Toronto, Vancouver, Calgary, and Brandon, Manitoba.88 If a province needed the assistance of any of these teams, a province-to-province request would be made under this memorandum of understanding. The expectation is that the team will be deployed if it is available.89

  • Chapter 2 Background of Responders and Emergency Management 19

    The role of the federal governmentIf an emergency requires support or resources beyond what a municipality or the province is capable of providing, the province can make a formal request for assistance from the federal government. Municipalities may not apply directly for federal emergency assistance, which would include assistance from the military.90

    The federal government intervenes in an emergency in a province only when requested to do so by provincial emergency management organizations or when an emergency clearly will have an impact on areas of federal jurisdiction91 – such as emergencies created by acts of terrorism.92

    Incident Management System: the system as it is intended to workThe Incident Management System (IMS) is a doctrine sponsored by the Government of Ontario which is intended to provide a single, province-wide system for emergency management and to be used by the various response organizations in the province. In this section of the Report, I describe in summary form how IMS is intended to operate. I will not, at this time, comment either on its efficacy or the extent to which it was followed in the response to the collapse of the Algo Mall. That analysis will come later in the Report.

    Background and purpose of the Incident Management System

    The Government of Ontario developed the IMS doctrine in an attempt to coordinate emergency management among the affected community and the related organizations, institutions, and industries. The stated objective is to provide a “flexible, scalable and consistent IMS structure and process for all levels of government, emergency response organizations, communities, ministries, NGOs and the private sector.”93

    The IMS was sponsored by Emergency Management Ontario and developed by a steering committee and several working groups made up of representatives from organizations involved in emergency response, including fire services, police services, and governmental departments. Their work produced the IMS doctrine, a 140-page document in which the system is described. The IMS doctrine was ultimately approved on January 30, 2009, by the Ontario government.94

    The impetus for developing this doctrine arose following the terrorist attacks in New York City, Pennsylvania, and Washington, DC, in September 2001. In the wake of that event, as well as other more recent emergencies including the 2003 Severe Acute Respiratory Syndrome (SARS) pandemic, the provincial government struck a commission to review Ontario’s emergency response capabilities and to make recommendations for improvement.95 The commission noted that the response to SARS, which was principally a health emergency, involved many different disciplines, including police and fire services. In view of the myriad organizations that can be called upon to respond to an emergency in Ontario, the commission recommended that a common protocol system be put in place so that the management of an emergency involving different response organizations could be coordinated more easily.96

    The IMS doctrine was originally premised on a similar emergency response regime, the Incident Command System (ICS), which had been developed by the fire service.97 The IMS was developed for the purpose of expanding the ICS so that other responding organizations could be similarly organized in an emergency.98

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process20

    In emergencies such as SARS and, indeed, the response to the collapse of the Algo Mall, different response organizations, which do not typically coordinate their operations, are called upon to work together. The IMS purports to coordinate a uniform response protocol among entities responding to a particular emergency. It seeks to establish a standardized organizational structure that may be distinct from the individual responding organization’s day-to-day administrative structures. The stated purpose of having a standardized organizational structure is to help different organizations work together in an emergency response – including by establishing clear terminology and roles.99

    The Incident Management System is not mandatory

    As noted, one of the stated primary purposes behind the development of the IMS doctrine was to provide one standardized emergency response system across Ontario so that different entities, individuals, and organizations

    can more effectively respond to emergency incidents.100 Indeed, the provincial government “recommends” that the IMS be used for managing all incidents.101 However, the IMS is not mandatory; rather, it is voluntary.102 In fact, it provides that responders are able to use only those aspects of the doctrine that are suited to a given incident.103

    As a practical matter, therefore, organizations that are involved in emergency response – such as fire, police, and emergency management services – are not required to use the IMS doctrine in their day-to-day operations. It exists theoretically and may be used within emergency response organizations selectively, or, presumably, not at all. In his evidence before the Commission, Mr. Hefkey was not able to advise what percentage of emergency response organizations in the province actually use the IMS doctrine in their operations.

    It follows that certain emergency response organizations use IMS more than others do and have a correspondingly greater familiarity with its components. Accordingly, not all response organizations share the same level of understanding of the doctrine.

    In introducing the doctrine, the province recognized that achieving a standardized IMS that “cuts across organizational boundaries may necessarily involve cultural shifts, over time, among some incident management practitioners.” The province also stated that “province-wide implementation is envisaged over time … The expectation is that gradually all of Ontario’s response organizations will implement the IMS and will train their personnel in the content of this doctrine to the extent deemed necessary by their respective organizations.”104

    The extent to which Ontario’s emergency responders exhibited familiarity with the IMS will be considered later in this Report.

    Incident Management System organizational structure and management functions

    Five major management functions provide the foundation on which the IMS is structured. These five are command, operations, planning, logistics, and finance and administration.105 These functions must form part of every incident response.106 The IMS literature depicts the structure as in figure 2.2.2.

    One of the stated primary purposes behind the development of the IMS doctrine was to provide one standardized emergency response system across Ontario so that different entities, individuals, and organizations can more effectively respond to emergency incidents.

  • Chapter 2 Background of Responders and Emergency Management 21

    CommandCommand is the paramount organizational component of the IMS structure. It is the act of directing, ordering, or controlling the operation of an emergency response.107 Incident command is responsible for managing the response to an emergency event.

    Under the IMS doctrine, there are two models of incident command that may be used during an incident: single and unified. A single command model may be arrived at by default when only one jurisdiction or organization is involved; by the nature of the emergency; or by legislation, if the responsibility is legally that of a single jurisdiction or organization.108

    In a unified command situation, two or more organizations that are participating in the emergency response designate members to be a part of the unified command. Those participants are intended to work together to establish and implement a common set of objectives. It is, in essence, command by committee. Unified command is to be used on rare occasions when incident decision-making is complex, interdependent, and a single command cannot be established.109

    The incident commanderThe individual who exercises the command function is known as the incident commander. An incident commander has overall authority and responsibility for conducting emergency response operations and is responsible for the management of all operations at the location of the incident. In a single command situation, only one person will exercise the function of the incident commander at any one time. Therefore, while several jurisdictions may respond, there will be only one incident commander.110

    The IMS is intended to operate so that all responders from different jurisdictions and organizations are working toward a common goal. It contemplates the integration of resources and personnel, with the result that the incident commander may be from a different service than many of the other responders. This arrangement creates a cultural anomaly where persons can be commanded by individuals who are not from their own organization or who may even hold a lower rank.

    Assuming incident command means taking overall responsibility for managing the incident and providing the overall leadership. According to the IMS doctrine, command must be clearly established at the beginning of an incident and maintained until the end.111

    Figure 2.2.2 The Incident Management System organizational structure

    Source Exhibit 887

    Command

    Operations Planning LogisticsFinance /

    Administration

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process22

    Although there is only one incident commander, that function may transfer from one individual to another. Any such transfer of command always requires that there be a full briefing for the incoming incident commander and notification to all personnel that a change in command is taking place.112

    The incident commander’s responsibilities include

    • ensuring the safety of all responders;• assessing and reassessing the situation, which may require obtaining information from other

    levels of response;

    • determining goals, strategies, objectives, and priorities appropriate to the level of response;• establishing an appropriate command structure using the IMS;• coordinating all incident management activities;• coordinating overall incident activities with other levels of response;• establishing and maintaining liaison with supporting or assisting organizations;• providing information to and briefing senior and elected officials as required;• establishing or activating Incident Management System facilities;• establishing an operational planning cycle;• approving an incident action plan (described in greater detail below);• managing incident resources;• authorizing the release of emergency information to the public in co-operation with the other levels of

    response, including information that would be disseminated by a Community Control Group; and

    • ordering incident demobilization.113

    Operations, planning, logistics, and finance and administrationUnder the incident commander are the operations, planning, logistics, and finance and administration spheres of responsibility. Each of these sections is commanded by a section chief. The section chiefs may well be from different services than the incident commander.

    The Operations Section is intended to implement the incident action plan.114 This section is responsible for assigning and supervising all resources assigned to an incident, and it should work closely with Command to coordinate operational activities.115

    The Planning Section is intended to develop the incident action plan. Its responsibilities may include collecting, evaluating, analyzing, and disseminating information related to the emergency response, as well as maintaining incident documentation, tracking resources assigned to the incident, and conducting long-range and/or contingency planning.116

    The Logistics Section is intended to provide supporting resources to the emergency response. Such support could include electronic communications, equipment, medical-related assistance, and other supplies such as food.

    The Finance and Administration Section is intended to provide the financial and cost analysis support to the incident.117

    The IMS is designed to be an organizational model that is scalable – that is, adjustable to respond to the magnitude of a response. It attempts to provide a template of how the organizational structure within these primary management functions can expand and contract as the situation dictates.

  • Chapter 2 Background of Responders and Emergency Management 23

    The incident action planEstablishing an incident action plan is one of the major responsibilities for an incident commander. Although it is developed by the Planning Section, it must be approved by the incident commander. Every incident must have an incident action plan. Its purpose is to provide all incident supervisory personnel with direction for the actions that are to be implemented in the course of the emergency response.118

    The essential elements of an incident action plan, as stated in the IMS, are

    • a statement of objectives expressing in a measurable manner what is expected to be achieved;• clear strategic direction;• the tactics to be employed to achieve each overarching incident objective;• a list of resources that are assigned;• the organizational structure / chart; and• safety guidelines or requirements.119

    While an incident action plan is required in all incidents, the nature of a given emergency response should dictate the level of detail in which the plan is prepared. According to the IMS doctrine, incident action plans can be oral or written. An oral plan may be sufficient when managing a simple incident, but a written plan should be used when dealing with complex incidents.120 A simple incident is one that can be handled routinely, requires few resources, and is relatively short in duration. Managing simple incidents does not normally require dependence on resources outside those that are available in the immediate area.121

    Complex incidents typically arise in one of two ways: they are either immediately complex (for example, a tornado that passes through a community), or they become complex (as in an isolated disease that becomes a pandemic). Complex incidents usually have some or all of the following characteristics:

    • prolonged duration requiring major changes in personnel or involving successive operational periods;• breadth of scale requiring a large number of resources;• multiple jurisdictions involved;• special knowledge and/or training required to resolve;• significant risk to the responders or the jurisdiction as a whole;• potential to cause widespread damage;• more complex organizational structure required; and• formal planning necessary.122

    Whether for a simple or a complex emergency response, an incident action plan is developed through the following steps:

    • assessment of the situation: “size-up” the situation to determine the nature of the problem;• establish incident objectives and strategy: determine the overall plan to meet the objectives of the

    emergency response;

    • develop the plan: ascertain the tactics that will be required to carry out the strategy, including detailing how resources will be deployed and developing an organizational structure for the response;

    • implement the plan: orders and directives are issued from incident command and the Operations Section for the purpose of carrying out the incident action plan; and

    • evaluation: constantly assess and re-evaluate objectives, strategies, and tactics to ensure the effectiveness of the plan’s implementation.123

  • Report of the Elliot Lake Commission of Inquiry Part Two n The Emergency Response and Inquiry Process24

    Planning cycleAs part of the development and implementation of the incident action plan, the IMS provides for a planning cycle. Its primary purpose is to facilitate, through designated meetings and forms, continuous evaluations and assessments of the objectives, strategies, and tactics that are developed in the plan and that are implemented in the course of the emergency response.124

    As depicted in IMS literature, the planning cycle is intended to function in accordance with the organogram set out in figure 2.2.3:

    The incident action plan is to be developed at a planning meeting. Individuals involved in the command and operations of the emergency response are to attend the meeting. Following the meeting, an incident action plan is to be prepared and approved. As noted, the plan can be written or oral. However, the more complex the incident, the greater the necessity for the plan to be written.125

    Following preparation and approval of the incident action plan, the next suggested step in the IMS planning cycle is an operations briefing. It is intended to ensure that everyone in the emergency response structure is aware of the strategy and the tactics that will be deployed in the execution of the plan.126

    Figure 2.2.3 Organigram of the Incident Management System planning cycle

    Source Exhibit 887

    IMS PLANNING CYCLE

    Pre-Planning Meetings (optional)Objective: In preparation for the main Planning Meeting, a series of pre-planning meetings are held as necessary. Initial Command

    Meeting (If applicable)

    Objective: Key officials discuss important issues. Determine need for unified command and make appropriate arrangements. Lead: Members of the Unified Command team (if established).

    Incident Briefing

    Objective: Provide situation awareness to activated staff or incoming CommanderLead: In-place Commander or OSCAttendees: Incoming Commander and/or PSC, other staff as required. Forms: Present IMS 201 Incident Briefing Form.

    Notification and Initial Response

    Objective: Management of initial response activities, including the activation staff, facilities, and resources.Lead: Commander or Duty Officer Attendees: All (as required)Forms: Develop IMS 201 Incident Briefing Form

    Command Objectives/Strategy Meeting

    Objective: Command establishes: incident mission, objectives, strategies, priorities.Lead: CommandAttendees: PSC, OSC, others as requiredForms: IMS 202 completed during or after meeting and signed by Command.

    Command & General Staff Meeting

    Objective: Mission, obj


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