88954_00a_prelimA.indd 1 11-10-07 10:39:59 Members of the Commission Mr. Pierre Marc Johnson, attorney, President Mr. Armand Couture, engineer, Commissioner Mr. Roger Nicolet, engineer, Commissioner Secretary of the Commission Ms. Nicole Trudeau, lawyer Graphic design and art direction Ms. Martine Desprez, graphic designer Printer Transcontinental Métrolitho Registration of copyright – 4th quarter of 2007 Bibliothèque et Archives nationales du Québec Library and Archives Canada ISBN 978-2-550-50961-5 © Gouvernement du Québec – 2007 88954_00a_prelimA.indd 2 11-10-07 10:39:59 Throughout its inquiry, the Commission has sought to understand the causes and the circumstances of the tragic events that occurred on September 30th 2006. In the memory of Mathieu Goyette Véronique Binette Jean-Pierre Hamel Sylvie Beaudet Gilles Hamel In tribute to Gabriel, son of Jean-Pierre Hamel and Sylvie Beaudet Mélanie and Yannick, children of Gilles Hamel The persons who were injured Louise Bédard Paul Cousineau Claude Bastien Mohamed Ashraff Umerthambi Anne Leblanc Robert Hotte To all persons whose lives where touched. 88954_00a_prelimA.indd 3 11-10-07 10:40:0 88954_00a_prelimA.indd 4 11-10-07 10:40:0 Montréal, le 12 octobre 2007 Monsieur Gérard Bibeau Secrétaire général du Conseil exécutif Ministère du Conseil exécutif 885, Grande Allée Est Édifi ce J. 2me étage Québec (Québec) G1A 1AZ Objet : Rapport d’enquête sur l’effondrement d’une partie du viaduc de la Concorde Monsieur le Secrétaire général, Nous, les Commissaires, conformément au mandat qui nous a été confi é par le décret 875-2006, pris le 3 octobre 2006 et conformément à la Loi sur les commissions d’enquête, vous soumettons respectueusement notre rapport d’enquête. Pierre Marc Johnson, avocat Président Armand Couture, ingénieur Commissaire Roger Nicolet, ingénieur Commissaire 88954_00a_prelimA.indd 5 11-10-07 10:40:0 This English language report is a translation of the original French version. The French version prevails. All the evidence adduced during the Commission’s public hearings has been made available along with this report, thanks to DVD technology; those interested can access all of the same at www.cevc.gouv.qc.ca, where they may also review our hearings in audio, video and written formats. 88954_00a_prelimA.indd 6 11-10-07 10:40:0 Report of the Commission of inquiry into the collapse of a portion of the de la Concorde overpass FOREWORD OF THE CHAIR The sudden collapse of the de la Concorde overpass killed fi ve people and wounded six others. Not only did this event deeply distress the persons close to the victims; it also touched a great number of people, because it was an abnormal and intolerable event. It was essential to discover its root causes and to propose the corrective measures that need to be taken. Both physical and human causes explain what happened on September 30, 2006. Amendments to codes, standards and manuals, with the knowledge now available, will correct the former. As for the latter, we now know that nearly forty years ago, there was negligence on the construction site of the de la Concorde overpass, and lapses in the managing of the structure throughout its useful life. These problems must be prevented or corrected, so as to ensure citizens using our bridges and freeways that such a lethal and rare chain of circumstances and events does not recur. To prevent such events, there need be consistent awareness and vigilance in relation to the demanding discipline of building or managing structures. Our mandate was carried out with the utmost independence and transparency. Our conclusions as to the causes of the event are based on evidence adduced to us during our hearings. Our recommendations deal with modifi cations to the legal and administrative framework of structure building processes, inspections and repairs. They also address the importance of looking toward the future. I am convinced that they will not only correct the failures we observed but also durably improve the state of our bridges. A daunting task awaits Government and the hundreds of persons whose work is essential to ensure public safety and the maintaining of adequate and effi cient infrastructures. Before identifying and thanking those who have supported me in the task of chairing the Commission, I express appreciation to all those who have accomplished their duty as citizens in cooperating with the Commission by coming forward voluntarily, without being served summons, as witnesses and experts. This duty is not always easy to perform. It can be very intimidating to present oneself in public, under oath, and to speak openly and honestly about facts and doings of important institutions and organizations, and of persons working for such. I believe it would be useful to overhaul the dating Act concerning public inquiry Commissions, in particular to provide for protection of those who bring their cooperation to such public 88954_00a_prelimA.indd 7 11-10-07 10:40:0 Report of the Commission of inquiry into the collapse of a portion of the de la Concorde overpass processes. Drawing from the Charter of Human Rights and Freedoms, the Act should create an offense sanctioning those who threaten to or exercise retaliation against persons who have collaborated with a Commission and entrust a tribunal with adopting redress and punitive damages in such cases. I thank fi rst my two experienced and wise colleagues, Commissioners Armand Couture and Roger Nicolet, both remarkable engineers. Their contribution was paramount in defi ning the work programme of the Commission’s technical team, framing mandates of the experts looking into the causes of the failure of the bridge and in appreciating to its full extent the signifi cance of evidence relating to full thick slabs without shear reinforcement. We were thus able, in the course of our mandate, to provide information useful for the ministère des Transports du Québec’s action plan to identify and intervene toward vulnerable structures. Mr. Michel Décary, our chief counsel, a man of rare experience, conducted the preparatory work and hearings rigorously, with intelligence and honesty, and nurtured a strong team spirit. He could rely on the stamina and meticulousness of assistant Counsel Marie Cossette as well as on attorneys Jean-Patrice Dozois and Poseidon Retsinas, whose contributions were important. The general coordination of our work was under the responsibility of Attorney Nicole Trudeau, Secretary of the Commission. She was remarquable by her patient, effi cient and disciplined work, as was Monique Michaud, lawyer, clerk of our hearings, who managed the critical documentary part of our work exceptionally well. Engineer-lawyer Michel Lemoine and engineer Paul Croteau, Ph.D. proved remarkably effi cient in shedding light on the causes of the collapse and I thank them both for their particular contribution to serve the public interest and public safety during our mandate. Mr. Julien Lemieux and all his staff discreetly provided support services: administration, communications, and the technical and Internet wizardry that made it possible for citizens to follow the public hearings. I thank him and all the support staff that devoted unending hours, particularly in the last two months of our mandate. 88954_00a_prelimA.indd 8 11-10-07 10:40:0 Report of the Commission of inquiry into the collapse of a portion of the de la Concorde overpass Table of Contents I am thankful to Ms. Martine Desprez, coordinator for the French, English and electronic production processes, who put up with a quasi impossible, yet unavoidable time schedule. My gratitude goes to our special assistants, Vincent Regnault, Attorney and Mr. Guy Versailles, APR, for their multiple contributions and unrelenting completion of each and every mandate assigned to them. Finally, I thank everyone who has supported our work in so many ways, including Counsel of parties, the experts, and the numerous persons who took of their time to participate in the consultations that nourished the Commissioners in the formulation of their recommendations. To all those who will recognize themselves for their support, I express my gratitude because they have made my task easier as chair of the Commission d’enquête sur l’effondrement d’une partie du viaduc de la Concorde. Pierre Marc Johnson Chairman Montreal, October 12, 2007 88954_00a_prelimA.indd 9 11-10-07 10:40:0 Report of the Commission of inquiry into the collapse of a portion of the de la Concorde overpass Table of Contents INTRODUCTION OF THE COMMISSIONERS The Government has mandated the Commission to investigate the circumstances and causes of the partial collapse of the de la Concorde overpass and to make recommendations on the measures to take to ensure such an event never recurs. Our fi rst words are for the people who lost loved ones and for the injured and their families. The tragic event of September 30, 2006 caused fi ve deaths and disrupted the lives of many people for many years to come. We would like to express our deepest sympathy and hope that our investigation and the contents of this Report provide some measure of closure and help them understand how this tragedy came about. The Commission strictly followed the principles set out in the Krever case delivered by the Supreme Court of Canada in 1997 with regards to the power of inquiry commissions, even though the Court interpreted the federal Inquiries Act rather than Québec law. These principles are as follows: • A commission of inquiry is not a court or tribunal and has no authority to determine legal