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Report of the Elliot Lake Commission of Inquiry

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Report of the Elliot Lake Commission of Inquiry Report of the Elliot Lake Commission of Inquiry Executive Summary The Honourable Paul R. Bélanger Commissioner Report of the Elliot Lake Commission of Inquiry Executive Summary The Honourable Paul R. Bélanger Commissioner 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 978-1-4606-4566-6 (PDF) ISBN 978-1-4606-4565-9 (Print) © Queen’s Printer for Ontario, 2014 Recycled paper THE ELLIOT LAKE LA COMMISSION COMMISSION OF INQUIRY D'ENQUETE ELLIOT LAKE The Honourable Paul R. Bélanger, L'honorable Paul R. Bélanger, Commissioner Commissaire October 15, 2014 The Honourable Madeleine Meilleur Attorney General of Ontario Ministry of the Attorney General 720 Bay Street, 11th Floor Toronto, ON M5G 2K1 Dear Madam Attorney, I am pleased to deliver to you the Report of the Elliot Lake Commission of Inquiry in both its English and French versions, as required by the Order in Council creating the Inquiry. Part One examines the events leading up to the collapse of the Algo Centre Mall in Elliot Lake on June 23, 2012 and Part Two looks at the emergency response to the collapse. Both volumes contain my recommendations for changes to rules, regulations, practices and procedures related to the maintenance and inspection of publicly accessible buildings and the emergency response to disasters. The third volume is an executive summary. I hope that the Report will lead to a safer Ontario. It has been an honour and a privilege to serve as Commissioner. Yours very truly, Paul R. Bélanger Commissioner 2380 St-Laurent Blvd 2380, blvd St-Laurent Ottawa, Ontario K1G 6C4 [email protected] Ottawa (Ontario) K1G 6C4 Executive Summary Part One: The Events Leading to the Collapse of the Algo Centre Mall ..............1 A brief summary of my Part One recommendations . 31 Part Two: The Emergency Response .............................................37 Inquiry Process ................................................................62 A brief summary of my Part Two and Inquiry Process recommendations . 62 To the residents of Elliot Lake I thank you. Your personal and collective sacrifices are recognized throughout this Report. This community, at both the official and the individual levels, has made me and all members of the Commission feel welcome, appreciated, and at home in this beautiful and unique city. We will not forget the people of Elliot Lake. I have no doubt that the resilience this city has shown so many times before in its short boom-and-bust history will help it to pick up the pieces from this tragedy. PART The Events Leading to the Collapse of the Algo Centre Mall Summary of conclusions ........................................................4 The history of Elliot Lake ........................................................5 The causes of the collapse .......................................................6 Construction of the Algo Centre Mall .............................................6 Professional involvement ........................................................................ 7 The role of the Town of Elliot Lake during construction .......................................... 7 The parking deck ................................................................................ 7 The hollow core slabs ........................................................................... 7 The concrete topping ........................................................................... 8 Confusion about the actual load-carrying capacity of the hollow core slabs ........................... 8 Expansion joints ................................................................................ 8 The crack-control joints ......................................................................... 8 The placement of the insulation .................................................................. 9 The Harry S . Peterson waterproofing system ..................................................... 9 1980–5: The Harry S . Peterson warranty years .................................................. .10 Elliot Lake’s Property Standards By-law: complaint-driven and not enforced .......10 1986–99: The leaks persist until Algocen decides to sell the problem ..............10 The sale to Retirement Living: new owner, no new solutions ......................11 Retirement Living purchased the Mall in a secretive process .................................... 12 Retirement Living could have afforded to fix the roof but chose not to .......................... 13 A secretive City administration turns a blind eye to the leaks ................................... .14 2 Report of the Elliot Lake Commission of Inquiry Executive Summary 2005–12: The Eastwood years ..................................................14 2005: Eastwood purchases a “black hole” it could nevertheless have afforded to repair ......... .14 2005–7: Eastwood ownership begins; the City takes action but fails to follow up on its Notice of Violation ............................................................................. .15 2008: Much talk and deception, but no action to fix the leaks ................................... 16 2009: The City issues another order – with no results ........................................... .17 2010 to December 2011: Eastwood cannot sell the Mall and will not fix the roof; the City receives more warning signs ........................................................... .18 2012: Two more inspections – and two more missed opportunities ............................. .19 General conclusions ...........................................................22 Steel rusts ...................................................................................... .22 The Algo Mall’s design was ill conceived ........................................................ .22 The basic concept was faulty .................................................................... 22 The roles of the architect, the engineer, and the owner were confused and unorthodox ............... .22 The building, excluding the waterproofing system, met the then-current requirements of the Building Code, but the roof design was defective ............................................... 23 After construction: the role of the engineering and architectural professions during the existence of the Algo Mall .................................................................. .23 After construction: the role of the owners ...................................................... .25 Algocen: 1979–99 ............................................................................. .25 Elliot Lake Retirement Living: 1999–2005 ......................................................... 25 Eastwood Mall Inc. and Bob Nazarian: from 2005 to the Mall collapse ................................ 26 After construction: the role of the City of Elliot Lake ............................................ .26 The Ministry of Labour ......................................................................... .28 Summary ....................................................................................... 28 Addendum ....................................................................28 The anonymous letter .......................................................................... .28 The report ...................................................................................... 28 The unpublished chapters ...................................................................... 29 The government’s reply submissions ........................................................... .30 Conclusion ..................................................................................... .30 A brief summary of my Part One recommendations ..............................31 Part One The Events Leading to the Collapse of the Algo Centre Mall 3 Part One of the Report is dedicated to the memory of Doloris Perizzolo and Lucie Aylwin – the two women who died in the collapse of the Algo Mall on June 23, 2012. u On June 23, 2012, at precisely 2:18 p.m., the heart of Elliot Lake, Ontario, stopped beating. A portion of the rooftop parking deck of the Algo Mall collapsed onto the two floors below, sending tons of concrete, mangled steel, drywall, glass, and one vehicle crashing down. Large pieces of steel and concrete (“widow makers,” the rescuers called them) hung precariously over the huge pile of debris. The fallen escalators were barely held up by overstressed beams, threatening to drop further at any moment. The collapse was precipitous and came without warning. It shattered the city and transfixed the nation. It also took the lives of Doloris Perizzolo and Lucie Aylwin. Nineteen other people were injured. For the next 48 hours, local firefighters, along with search and rescue teams from Toronto and the Ontario Provincial Police, feverishly searched the rubble pile for survivors. They were encouraged by tantalizing indications that someone, miraculously, might still be alive under the wreckage. Then, suddenly, the rescue effort was halted – the risk of harm to the rescuers was deemed to be too great. Engineers advised that the entire remaining structure of the Mall was dangerously unstable. Unfortunately, no alternative plan had been developed, and, without direction, the rescuers gave up. Only after Premier Dalton McGuinty intervened on June 25 did the rescue operation resume, in the faint but rekindled hope that a specialized
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