Decades of incompetence, neglect, greed and dishonesty by a succession of owners, engineers and municipal officials led to the deadly cave-in of a northern Ontario mall two years ago, a judicial inquiry reported on Wednesday.
In a scathing indictment of those who allowed the Algo Centre Mall to rust to the point of collapse, Commissioner Paul Belanger pulls few punches.
"Although it was rust that defeated the structure of the Algo mall, the real story behind the collapse is one of human, not material, failures," Mr. Belanger told scores of residents at a community centre.
"Some of these failings were minor, some were not: they ranged from apathy, neglect and indifference through mediocrity, ineptitude and incompetence, to outright greed, obfuscation and duplicity."
On a sunny Saturday afternoon in June, 2012, the rooftop parking deck, weakened by decades of rust-causing water and salt penetration, crashed down.
Trapped in the rubble were Doloris Perizzolo, 74, and Lucie Aylwin, 37. Nineteen others were injured.
While Ms. Perizzolo's death was "mercifully quick," Ms. Aylwin might have lived for as long as 39 hours, Mr. Belanger concludes. He noted "tantalizing" signs she was alive for some time: responsive tapping, a muffled voice, indications from search dogs.
"There exists a possibility she might have been rescued," he writes in his 1,400-page report. "But we will never know for sure."
What is clear is that the disaster began unfolding in the 1970s. The mall, Mr. Belanger concludes, was "doomed to early failure" while still in its planning stages.
Putting parking on the roof was a bad idea. A defective design – using an untested combination of materials – made matters worse.
"The system was a dismal failure from the moment it was installed," the report states.
The report can be found on the inquiry's website.
The mall seldom lacked for professional oversight from architects and engineers, with some 30 visits, inspections and reports over its 33-year life.
However, the scrutiny never translated into a proper fix for the leaks that prompted some to dub the centre the "Algo Falls." No one appeared to realize how severely the rust would compromise the integrity of the structural steel.
Some of the engineers simply forgot the "moral and ethical foundation" of their vocation, Mr. Belanger concludes, and were more concerned with pandering to clients than protecting the public.
The commissioner was particularly critical of Robert (Bob) Wood, the engineer who said the mall was sound just weeks before it collapsed. His work and conduct, Mr. Belanger says, were "markedly inferior."
Mr. Wood, who faces criminal charges in connection with the collapse, admitted falsifying his report to appease the mall's owner.
"His review was similar to that of a mechanic inspecting a car with a cracked engine block who pronounces the vehicle sound because of its good paint job," the report states.
According to the commission, the mall's various owners hid the problems, then tried to sell their way out of them when patchwork fixes did not work. Profit considerations trumped all other concerns, Mr. Belanger says.
The "crafty" and intransigent Bob Nazarian, who owned the mall when disaster struck, lied about repair work, and resorted to "subterfuge and falsehood to mislead authorities, tenants and the public," the report concludes.
Willfully blind municipal officials – the mayor, council and building inspectors – ignored public complaints and warnings about the leaks and falling concrete. They illegally shut the public out of meetings. They failed to enforce, or were ignorant of, their own bylaws, according to the report.
Instead, their approach was one of "non-interference" aimed at safeguarding the mall as a social and economic hub that provided significant tax revenues.
At one point, Mr. Belanger notes, the municipality was the mall's owner, its tenant, and enforcer of property standards – the "worst possible conflict situation."
While townspeople appeared pleased with the report, many wanted to know whether others would face criminal action.
Ms. Aylwin's fiance, Gary Gendron, said the report brought him some peace.
"It's sad and it feels good at the same time," he said. "I feel a little bit better: somewhat of a closure, but more of a closure when there'll be some criminal charges laid."
The report also notes that officials with the provincial Ministry of Labour, which had offices in the mall, appeared curiously indifferent to the state of disrepair, and unresponsive to complaints.
The report from the $20-million inquiry makes 71 recommendations. They include setting minimum maintenance standards for buildings, beefed-up inspections, and an expanded emergency response capability.
Mr. Belanger praises the initial local emergency response, but says the provincial search-and-rescue team deployed without sufficient numbers, a proper plan or command structure, and treated family members and the community poorly.
The Ontario government promised a quick review of the recommendations to ensure the province is better prepared for any emergency.
Provincial police said they had improved to their crisis response, including mandatory training for major critical incident teams who are now deployed throughout the province.