The inquiry into an Elliot Lake mall collapse recommends changes which could improve disaster response, bolster the health and safety inspectorate and ultimately improve building safety.
Justice Paul Belanger’s two-volume Report of the Elliot Lake Commission of Inquiry
released October 15th
contains 71 recommendations. Part I examines events leading up to the mall collapse. Part II reviews the emergency response. The following summarizes the report’s key findings and recommendations as they relate to workplace health and safety issues.
An accident waiting to happen
Algo Mall was built in 1979. The roof leaked from day one. On June 23, 2012 a section of the mall roof deck collapsed from years of water and salt penetration which rusted a connection between a supporting column and beam. The collapse killed Lucie Aylwin, 37, a lotto kiosk worker, Doloris Perizzolo, 74, a customer and injured 19 others. Six days after the collapse the government announced an independent public inquiry.
Inquiry key findings
The Inquiry examined one million pages of documents and heard from 118 witnesses. Decades of poor oversight, lack of compliance and sheer incompetence contributed to the eventual collapse, concludes Commissioner Belanger. He adds, “...the real story behind the collapse is one of human, not material, failure….Occasional voices of alarm and warning blew by deaf and callous ears.”
The inquiry’s key findings include:
Recommendations for OHS
Faulty initial design and poor maintenance of the roof’s parking deck
Municipal officials ignored reports of leaks and failed to enforce property standards by-laws
Ministry of Labour (MOL) did not treat leakage complaints with concern
Several engineers failed to properly inspect the mall and crafted reports that may have downplayed leaks
All three mall owners carried out ineffective roof repairs and failed to report the history of leakage problems
Some search and rescue teams could have been deployed sooner
Lack of an action plan hampered rescue efforts as did poor communications
Ontario’s search and rescue system needs to be re-examined
Confusion about the MOL role in emergency response.
Chronic leaks at the mall went largely undocumented even when the MOL had an office there in the early years. In recent years, mall leaks were the subject of two complaints to the MOL, one of which was anonymous, and one visit.
The Inquiry Report suggests systems for handling complaints may be inadequate. “There were, over the years, numerous occasions when the health and safety committees of individual businesses met to deal with leakage problems. Their concerns rarely made it to the attention of the Ministry of Labour. It may very well be that the ministry’s internal responsibility system acts as a disincentive to the reporting of problematic conditions. Employers may not be motivated to invite scrutiny for fear of the potential financial consequences, and employees may be apprehensive about the security of their employment.”
Seven of the report’s recommendations are addressed to the Ministry of Labour. These include new mandatory requirements for:
employer reporting to the MOL of complaints regarding a building’s structural soundness and watertightness
standards related to pro-active inspections and responses to such complaints
reciprocal reporting between key municipal and MOL staff regarding reports of possible breaches in structural adequacy standards or Occupational Health and Safety Act provisions.
Further, the commission report advised the MOL to:
Elliot Lake — In perspective
Provide “comprehensive” training for MOL inspectors on building structures, safety and watertightness and,
Clarify their role in emergency response situations.
With attention focused on the collapse and subsequent rescue and recovery, it’s easy to forget that Algo Mall was also a workplace. Lucie Aylwin lost her life working at the mall’s ticket kiosk but many more workers could have perished. Retail and service workers, often employed in small workplaces, lack access to joint health and safety committees, worker representatives or unions. As a result, their health and safety concerns may go unheard.
Elliot Lake is well known for its pioneering health and safety efforts. Workers Health & Safety Centre executive director, Dave Killham, weighed in after the Report’s release: “The irony of this commission report being released in the same year we marked the 40th
anniversary of Elliot Lake miners taking the rare step of striking for the resolution of health and safety issues has not been lost on those of us at the WHSC. This brave act and an ensuing lobby by workers and their representatives also led to an independent commission of inquiry and ultimately Ontario’s Occupational Health and Safety Act
, which when properly enforced offers some measure of protection for Ontario workers. It is our sincere hope that similar advances will come of Paul Belanger’s commission report.”
“I note as well, the Belanger commission report calls into question the Ministry of Labour internal responsibility system, now under review by the Ministry-led mining health and safety review for Ontario,” says Killham. “At the WHSC we are working to ensure the internal responsibility system doesn’t devolve into the “individual” responsibility system as some would have it. Rather than seeking to download employer responsibilities to individual workers, WHSC programs and services are dedicated to supporting collective action, through the work of joint health and safety committees and worker health and safety representatives. The evidence shows us when properly supported JHSCs and worker reps can significantly contribute to creating safer, healthier work.”
The government says it is reviewing the inquiry report. They have initially committed to implement some recommendations including: clarifying the role of MOL inspectors and engineers during rescue and recovery efforts and providing recommended training for MOL inspectors.
The MOL has also said it will hire seven additional engineers to support inspectors in their field work, including a structural engineer to service Northern Ontario. The government has agreed to report back on their progress in implementing recommendations within one year.
Visit the Elliot Lake Inquiry
web site for access to the full Report and all supporting documents.
Read Ontario's commitments in response to the Inquiry Report
For its part, the WHSC remains committed to workers and workplaces across the province in every sector of the economy. WHSC offers more than 200 training programs which meet legal training mandates and cover a wide range of hazards and sectors including training for retail
and small workplaces
. Review WHSC’s online training catalogue
Don’t see what you need? Contact WHSC and ask to speak with a training service representative to help you access the right information and training for your workplace.