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Firefighters climb a ladder at the scene of a fire in Old Montreal on March 16 where seven people died.Graham Hughes/The Canadian Press

A confidential report obtained by The Globe and Mail says the decade-old suicide of a Montreal fire department official and the ensuing turmoil, combined with regulatory changes and years of miscommunication, led to the adoption of several long-standing moratoriums on the enforcement of safety standards.

The comptroller-general’s report, signed by senior auditor Étienne Quenneville, was commissioned by Montreal Mayor Valérie Plante on May 16, 2023, a day after The Globe revealed the existence of moratoriums that may have played a role in the city’s deadliest blaze in decades.

On Oct. 19, 2012, Stéphane Archambault, a 48-year-old section chief in the fire department’s prevention branch, died by suicide. Media reports at the time linked his death to a toxic work climate, plunging the department “into a major internal crisis,” according to Mr. Quenneville’s report, dated July 14, 2023.

“Everything indicates that 10 years later, traces of the crisis still linger” within the prevention branch, which “does not seem to have fully recovered from the events,” the report says.

After Mr. Archambault’s death, a deputy director and several division chiefs left the department without transferring files to their successors. “Major and strategic projects” were abandoned, contributing to establishing and maintaining moratoriums, which the report describes as “suspensions of activities.”

The prevention branch was never able “to structure itself effectively and permanently” and staff raised persistent issues: “Working in silos, lack of listening and communication, lack of supervision and training are terms that were repeated,” the report says.

“We are especially concerned by the lack of follow-up, the deficiencies in collaboration and communication and, consequently, by the delays in reaching a formal conclusion on the status of the activities, some of which have been suspended for more than 10 years,” Mr. Quenneville wrote.

City of Montreal spokesperson Gonzalo Nunez said the report “was in no way intended to be distributed outside the municipal organization” and declined to answer any of The Globe’s questions on its content.

In May, The Globe found that a suspension of activities relating to evacuation routes prevented legal proceedings against the owner of a historic district building where multiple safety issues were flagged between 2009 and 2020. Seven people died when this property burned on March 16, 2023.

Internal correspondence shows the fire department connected the fatal incident and moratoriums early on.

On March 20, as crews were still searching the rubble for bodies, fire department division chief Marcel Deschamps sent an e-mail to other officials with the property’s address as the subject line. The e-mail lists documents to be added to a file, including a history of inspections and “as prevention, the history of moratoriums.”

Minutes later, Chantal Bibeau, the fire department’s deputy chief for prevention and risk management, forwarded Mr. Deschamps’s e-mail to another department official, saying: “FYI and discussion regarding the eventual COMM strategy.” This was weeks before The Globe sent questions regarding moratoriums.

A criminal investigation into the Old Montreal fire, which the police say was arson, is continuing, and a coroner’s inquest will start once the police probe is completed. Montreal’s ombudsman is investigating what actions the fire department took in the years preceding the incident. Victims’ families, survivors, a neighbouring museum and the owner of the building have filed lawsuits against the city, citing poor enforcement.

The City of Montreal had previously declined to share the comptroller-general’s report despite multiple requests from The Globe, city hall opposition leaders and victims’ families, citing investigations and judicial proceedings.

But a mostly unredacted version of Mr. Quenneville’s report was included among a trove of documents obtained through an access to information request aimed at select fire department officials’ correspondence.

The 30-page report is part of a 3,000-plus-page file that includes partially redacted copies of e-mails, memos, other reports, presentations, collective agreements and entire laws. Also shared in other files appear to be several entirely redacted versions of the comptroller-general’s report.

E-mails show fire department officials had an opportunity to provide comments on a draft report submitted on July 7, but comments and the draft report were redacted or not included in the shared files.

Mr. Quenneville based his report on records including fire department e-mails, memos and inspection data, along with interviews with nine current and former unnamed staff and written exchanges with others.

The report, marked “confidential“ on every page, describes years-long suspensions of enforcement activities relating to fire-safety plans (enacted in 2009), capacity cards (2010), evacuation routes (2018), smoke detectors (2019) and alarm systems (2021).

As The Globe previously reported, the enforcement of evacuation route and alarm system regulations was taken up again in April, 2023, as a direct result of the Old Montreal fire, while legal proceedings for non-compliant smoke detectors resumed in October. The two other suspensions of activities remained in place.

Mr. Quenneville’s report looks back to 2008, when Montreal’s auditor-general, an independent oversight body examining the city’s management of public funds and compliance with the law, produced a scathing report on the fire department.

The auditor-general noted that Montreal’s then 25 fire prevention regulations were putting a heavy burden on staff. He also found deficiencies including a lack of planning and follow-up of inspections and non-conformities, work being done in silos and poorly prepared files often inadmissible in court. These had “an impact on public safety” and could “expose the Department to criticism in the event of a fire,” he wrote.

In a 2010 follow-up report, the auditor-general noted that 19 of his 20 recommendations were still “in progress,” with some deadlines extended to 2013.

More than a decade later, some of the same issues persist, according to the comptroller-general’s report. (The comptroller-general has a similar mandate to the auditor-general but reports directly to the city’s general manager.)

A new deputy director was appointed in 2010 to reorganize fire prevention through a “standardization of activities process” (SAP). This man, Pierre Sigouin, was identified in media reports as responsible for the toxic work climate that led to Mr. Archambault’s suicide in 2012. He was suspended in 2013.

The comptroller-general’s report says that “witnesses reported that the SAP was the initial cause of the suspensions of activities.” But Mr. Sigouin’s departure “considerably weakened the efforts put into the SAP and led to its abandonment,” including steps related to fire-safety plans and capacity cards, which indicate the maximum number of people permitted in a particular space.

In 2017, as part of regulatory changes aimed at standardizing rules, the fire department inherited responsibilities previously held by the Régie du bâtiment du Québec (RBQ), which regulates and enforces building construction and safety in the province.

Instead of adapting its activities, the fire department gave up on enforcing alarm system upgrades and what it calls construction-related elements of evacuation routes, which include things such as the number of exits in a building. Internal memos cite a lack of staff training, uncertainty about what a return to compliance looked like and difficulties meeting the municipal court’s burden of proof for fire-safety infractions.

According to Mr. Quenneville’s report, the RBQ was supposed to support the fire department after 2017, but witnesses said it failed to do so.

One of them said he received three different interpretations of the alarm systems regulations from the RBQ. Another said the RBQ “transferred a significant number of unprocessed reports” to the fire department – reports the department had itself sent the RBQ when the provincial agency was in charge.

The comptroller-general’s report does not address the fatal March, 2023, fire. However, the regulatory ping-pong it highlights between the fire department and the RBQ sheds new light on facts uncovered by The Globe over the past months.

In 2011, a fire department inspector sent a complaint to the RBQ about the Old Montreal property, noting that “the configuration of the means of evacuation is non-compliant.”

In 2013, the RBQ sent a correction notice to the building’s owner, Emile-Haim Benamor, about alleged violations including the lack of a second exit on the third floor and a dead-end hallway on the second floor. The RBQ deemed the building still non-compliant as of 2018 and no records show these issues were ever addressed.

The RBQ has declined to share any documents related to the building. The Globe shared excerpts of the comptroller-general’s report with the RBQ, but spokesperson Laurent Bérubé declined to answer questions on its content.

Regarding alarm systems, the comptroller-general’s report offers more details on the reasoning behind the suspension in 2021. It quotes an e-mail sent by the city’s legal department saying that fire department staff failed to take basic steps to secure convictions including confirming the identities of non-compliant buildings’ managers with whom they interacted or formally notifying building owners when they requested documents.

The comptroller-general’s report says the decision to resume or maintain suspended activities “must be carried out as part of an overall risk analysis.” It makes no recommendation other than asking for “clear communication on their status” to be shared with Ms. Bibeau’s staff.

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