Hawkesbury fire department's performance 'substandard' in fatal fire
The performance of the fire department in Hawkesbury, Ont., during a retirement home fire that killed an elderly couple was "substandard" and "inadequately managed," according to the findings of an internal police report.
The report, commissioned by the Ontario Provincial Police and obtained by CBC News under a freedom of information request, concerns how the department responded to the May 25, 2012 fire at Place Mont-Roc at 100 Industriel Blvd.
Some 90 people fled the fire or were evacuated by firefighters.
However, Marie-Anne Bonin, 84, and Jean-Paul Bonin, 86 were trapped inside and died in the fire, which started outside their bedroom door.
There were no other injuries.
Cause still undetermined
Preliminary findings by fire officials indicate the fire likely originated near a couch located in a public corridor on the third floor of the complex.
The fire's cause is still under investigation by the Ontario Fire Marshal's office, but the OPP's crime unit commissioned CFT Engineering Inc. to provide their own analysis.
The B.C.-based engineering firm specializes in fire protection and building code issues. Its findings are contained in the report from 2016, four years after the fatal blaze.
The report found deficiencies linked to the design and construction of the building — most notably, that it didn't have a mandatory sprinkler system due to being misclassified under the Ontario Building Code.
The report also pointed to the complex not having a standpipe and hose system, noting the lack of one "contributed to fatalities."
The furniture — which was not permitted to be in a public corridor — did not comply with Ontario's fire code and was a "major factor in the severity and outcome of the fire," the report said.
The report's most scathing conclusions, however, are directed at the Hawkesbury Fire Department, which it described as having "multiple oversights during the emergency response," including:
A "delayed" response arriving on scene due to the fact the fire alarm system wasn't working and a staff member had to call first responders. Wiring deficiencies had been found in the alarm system as far back as 2002, but records indicated the issue wasn't appropriately addressed — yet fire prevention officers gave the home a passing mark on inspections.
Several miscommunications, including one that resulted in a 30-minute delay in getting water from the pumper truck to the fire fighters with the hoses. The delay was caused by a valve set in the wrong position, the report said.
A failure to follow standardized searching techniques during the first search of residents' rooms. Firefighters didn't mark the doors of the rooms they'd checked — leading to the mistaken conclusion during a second search that the room where the Bonins died had already been searched. The report called the searches a "failed exercise."
A "preventable" miscommunication caused by a shortage of portable radios.
The fact firefighters didn't have axes to break into rooms with locked doors.
The report also noted that the fire was of limited size and could have been extinguished with portable extinguishers located near the fire zone.
"The performance of the Hawkesbury Fire Department, within the context of this event, was 'substandard' and 'inadequately managed,' given the response was not pre-planned, the failed search for occupants, and extinguishment being delayed for 30 minutes," the report said.
The report did acknowledge there are also many factors beyond control in an emergency.
'Subject to interpretation'
Roger Champagne, Hawkesbury's current fire chief, declined an interview and referred the request to Daniel Gatien, chief administrative officer for the municipality.
We have an excellent fire department and we have total confidence in the way our fighters respond to all emergencies. - Daniel Gatien
"Well, listen, obviously there's a lot of information that was identified in the report — justified or not, I really don't know. It's obviously something that needs to be reviewed," Gatien said.
"It's the opinion of an engineer and it's subject to interpretation"
The Hawkesbury fire department currently has five full-time firefighters and 20 volunteers trained by the province's fire college, Gatien said.
"We have an excellent fire department and we have total confidence in the way our fighters respond to all emergencies," he said.
Charges still possible
Place Mont-Roc is now owned by Frank Zambito, who told CBC News in an email that any comments about the fire should come from the long-term care home's previous owners.
He did say that a "state-of-the-art" sprinkler system has since been installed.
In an emailed statement, the OPP said the investigation into the cause of the fire is continuing with the Ontario Fire Marshal's office.
While the OPP aren't ruling out criminal negligence charges, for now, the police force says there's insufficient evidence.
The force has also requested a coroner's inquest, but that request is pending given the outcome of the fire marshal's report.
