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globe investigation

Canadians make 12 million calls to 911 every year, and they take it for granted that when they dial those three digits, help will find them.

That's how it was for Melvin and Khadija Luck. In April, they made a frantic 911 call. Their 18-month-old son, Elijah, had stopped breathing and was turning blue. While the Lucks waited for an ambulance at their Calgary home, a terrible mix-up unfolded three provinces away: The family's Toronto-based Internet phone company mistakenly dispatched an ambulance to the Lucks' old address in Mississauga. By the time help arrived almost half an hour later, it was too late for Elijah. He died in hospital.

"It has shaken us completely," Mr. Luck said this week. "The doctors said if the ambulance had come within five minutes, my baby might be alive. There are no guarantees, but I believe that he would still be here."

The breakdowns that preceded Elijah's death were not isolated mistakes. In a six-month investigation of Canada's 911 service, The Globe and Mail found that a lack of federal oversight, regulatory loopholes and outdated technology have left this country's emergency dispatchers scrambling to locate callers who dial 911 from cellphones or from Internet phones.

There are now nearly 21 million wireless subscribers in Canada. More than half of all 911 calls placed each year are made on cellphones, and 250,000 Canadian homes have the same kind of voice-over Internet Protocol phones the Lucks used the day their son died. Yet the relatively cheap technology that would allow dispatchers to find cell and Internet phone users isn't in place in Canada. If these callers can't speak, or don't know where they are, 911 dispatchers can't find them.

This failure had fatal or near-fatal consequences in at least four cases this year, including Elijah's and that of a 39-year-old man beaten and dumped in a field he didn't recognize near Brooks, Alta. He called 911 from a cellphone. Police found his body two days later.

The Globe's investigation found that Canada's telecom regulator, which sets the rules for 911, knew it had a serious problem on its hands long before this year's deaths.

For example, four years before Elijah Luck died, the Canadian Radio-television and Telecommunications Commission was alerted to at least 72 similar mix-ups involving 911 calls made from Internet phones. Those included an Arizona 911 call mistakenly connected to dispatchers in Toronto and several emergency calls from Ontario and Quebec that couldn't be traced.

The misdirected calls prompted the CRTC and Canada's voice-over Internet phone companies to draft a solution that might have saved Elijah's life. But the proposal sat on a shelf for more than a year before the toddler died while the regulator and the telecom sector bickered over who should pay to fix the problem, according to some of the 3,000 pages of documents obtained by The Globe, most under access-to-information laws.

"This needs to be fixed," Mr. Luck said. Judy Broomfield, the head of Toronto's 911 dispatch centre, said more tragedies are inevitable. "Right now there is no way to prevent another Calgary. I can sadly guarantee that," she said. "We have this happen all the time. We just haven't had anybody [else]die yet."


Two hours into his 911 cellphone call, Garth Pratt began to hallucinate. Through the frosted-over windows of his wrecked minivan, he could see the headlights of approaching cars and hear the sirens. He thought help was on the way. But on a barren stretch of Saskatchewan prairie the night of Jan. 16, there was nothing but the wind and the snow pounding against his vehicle, which had swerved off an icy road and rolled into the ditch.

The 33-year-old had no idea where he was. He hadn't paid any attention to how far he'd driven from the last town. Still dazed, he managed to dial 911 from his cellphone. The temperature was -39.

Ninety kilometres away in Saskatoon, regional 911 dispatcher Janice Marcotte had spent the past two hours on the phone, trying to keep Mr. Pratt talking until the ambulance arrived. Now hypothermia was setting in.

"I think I'm going to die tonight," he told Ms. Marcotte.

"No you're not. We're close, we're really close," she replied.

But they weren't. The dispatchers had little to go on. All they knew was the location of the cell tower picking up his signal, which narrowed the search to about 40 square kilometres.

"I had to put down the phone. It was too hard," Ms. Marcotte says. "I was listening to the guy die on the phone."

It took nearly 3 1/2 hours before emergency crews, including two RCMP cars and two ambulances, finally discovered Mr. Pratt on the side of the road. The dispatchers huddled by the radio for several minutes, listening anxiously until paramedics confirmed he was alive and took him to hospital.


Had the same emergency unfolded in the United States, crews could have located Mr. Pratt in less than a minute. In 2001, Washington mandated cellphone companies to update their network by 2005.

"We can do it in as little as 15 seconds," said Rob Anderson, the chief technology officer for TruePosition, a company that locates five million wireless calls a month in the United States, under laws that allow dispatchers to track cellular signals.

The techniques involve using Global Positioning System (GPS) data or receivers that triangulate the signal of the phone in relation to cell towers. In August, armed robbers burst into a suburban Philadelphia hotel and demanded access to the safe.

Unable to speak, a hotel clerk was able to dial 911 and let the phone fall to the floor. In minutes, police figured out the phone's location and the men were arrested.

"This technology is a decade old," Mr. Anderson said.

Washington strictly enforced the 2005 deadline and companies that didn't meet it paid hefty fines. Although it was a painful transition, it worked. Today, more than 87 per cent of the more than 6,100 emergency dispatch centres in the U.S. can locate the majority of the 911 calls from cellphones. That covers 93.1 per cent of the U.S. population, according to the National Emergency Number Association.

When it comes to locating calls, Canada is dangerously behind the times. Despite the proliferation of GPS-equipped cellphones, the ability to locate callers using GPS does not exist here.

To make matters worse, much of the technology needed to solve the problem is manufactured here, then exported to the United States where it is purchased by the major wireless carriers.

Gatineau-based SolaCom Inc., a company that designs such equipment, has contracts in eight U.S. states. Ottawa, meanwhile, has refused to impose a deadline.

Paul Godin, a CRTC director-general, said the regulator preferred a slower transition in which the phone companies work with dispatch centres to find a solution.

Canada began testing cellphone location technology only two years ago. Internal CRTC documents obtained by The Globe indicate the cellphone problem could be solved for $50-million. It is a relatively small amount for an industry that has billions in revenues each year, but the companies are locked in a bitter debate over who should pay, and the regulator has avoided forcing them to act. That has angered companies such as SolaCom. "The things that seem to be rather problematic issues are, at this stage of the game, rather trivial. They are very answerable questions and very affordably," said Allan Zander, head of SolaCom. "There has never been a line in the sand that says you must do it by this time."


The biggest impediment to a solution is that the wireless companies won't see any return on their investment if they pour money into updating their 911 technology.

The Canadian Wireless Telecommunications Association, lobbying on behalf of the cellphone companies, has insisted public funds be used to update Canada's 911 infrastructure, rather than phone company money.

"I'm not suggesting that the wireless industry has no interest in providing this," said Keith McIntosh, director of regulatory affairs for the association.

"The quickest way to get it deployed is to make resources available so that it's not a decision between expanding your network — an investment where there is a possibility of return — or this public service."

In addition to the municipal and, in some cases, provincial taxes that are used to fund the 911 system, cellphone companies also collect their own 911 fees.

Ms. Broomfield estimates Canada's wireless companies collect a total of about $157-million a year from 911 fees. Those charges are between 50 cents and $1 per month in most provinces. While a portion of that money, about a dime, goes toward the 911 system, the CRTC does not regulate where the rest goes.

These fees have long been controversial; however, while the telephone companies use them to cover various 911 costs, they are not required to disclose where all of the money is spent.

An internal Industry Canada document indicates the government was advised that the money is "retained as additional revenue" by the wireless companies. While the debate drags on, the problem persists.

In September, five men beat 39-year-old Sharmarke Wasame, a Somali immigrant, and dumped him in a field near Brooks, Alta. He didn't know where he was. He called 911 from a cellphone. Using the cell tower picking up his signal, police narrowed the search area to 15 kilometres. They found his body two days later, after a helicopter was brought in to search the area.


Another problem with the system's ability to handle 911 cellphone calls emerged in August, when several drivers in Ottawa stopped to help April Nauta, a 27-year-old cyclist who had been struck by a car near the provincial boundary with Quebec.

The drivers were stunned when they called 911 and were told to hang up and dial another number. Their signals had jumped across the Ottawa River to Gatineau, where dispatchers would not take the call.

As Ms. Nauta lay dying from her injuries, the 911 callers soon learned the backup number they had been given for Ontario police did not work, compounding the situation.

Ontario's Minister of Community Safety later wrote in a letter to his Quebec counterpart that he had no idea the backup numbers weren't valid on all cellphones. Ms. Nauta died in hospital.

Police say her head injuries were so grave a faster ambulance response probably wouldn't have saved her. Still, the problem of cell signals jumping borders isn't isolated and it hasn't been fixed, in large part because Canada's 911 system remains a patchwork of jurisdictions.

Industry Canada documents indicate the government discussed creating a national 911 network in January of this year, which may have helped to solve these problems.

It appears the idea was explored only in conversation. The foot-dragging has baffled observers outside Canada.

"Let's put it this way," said Jeff Robertson, head of a Washington-based lobby group called the 911 Industry Alliance. "If I had to dial 911 on my cellphone, I would much rather do it in the United States than in Canada."


The story of how voice-over Internet Protocol phones spread to some 250,000 Canadian homes without stringent 911 rules begins in 2004, when the CRTC held hearings to set rules for the new service.

At the time, federal regulators were keen to stoke the fledgling sector. Internet phone companies gave the CRTC something it craved: new competition in the home-phone market, which for decades had been the domain of major phone companies such as Bell and Telus, which held monopolies.

VOIP phones, which are regular phones plugged into modems, offer cheaper rates than the other companies because the calls travel over the Internet rather than traditional wires; the service is especially popular among immigrant families looking to make inexpensive overseas calls.

Even before the CRTC called the nascent industry to hearings, at least a half dozen companies were marketing their services in Canada with no oversight from the regulator.

With home phones, 911 dispatchers automatically know the address of an emergency because the phone number can be cross-referenced with a home address. With Internet phones, however, the equipment can be hooked up anywhere there is an online connection, and there is no way for the dispatcher to tell where the call is originating in cases where callers can't speak.

This raised alarms with some CRTC commissioners, even though Internet phone companies insisted they were working on the problem. "I don't want to be overdramatic, but if you were selling cars and you told us they didn't have brakes yet, but you were giving it your best shot, we would be nervous," Stuart Langford, a former CRTC commissioner, told industry executives in 2004, according to federal transcripts of those hearings.

During three days of hearings, at least three 911 dispatchers told the commissioners about a total of 72 separate cases of misdirected VOIP calls, clearly demonstrating the problem was bigger than an isolated case or two.

Don Workman, a telecom engineer for the City of Calgary — where Elijah later died — warned the situation "was unacceptable and poses a risk to the life and property" of callers in an emergency.

At the same time, however, Ottawa was facing intense lobbying from the new telecom players for hands-off regulation.

"It is in the public interest to encourage and promote these capabilities in order to maximize innovation … and to provide a greater choice for Canadians," Ted Chislett, president of Primus Canada, told the regulator, according to transcripts of the hearings.

Comwave, the company involved in the Luck case, told the CRTC that if the new phone companies were forced to develop proper technology to solve their 911 problem, it would make their service more expensive, effectively pricing them out of the market.

"The imposition of a single, one-size-fits-all 911 solution at this time would fetter and destroy new VoIP competitors," said Comwave chief executive officer Yuval Barzakay. "Let's wait to see where competition will be in five years. We believe there is always time to remove or add regulation as needed."


Less than a year after those hearings, the CRTC agreed to give Internet phone companies lighter 911 requirements than traditional phone companies.

Rather than connect directly to 911 dispatch centres, which was technologically challenging at the time, the CRTC allowed them to employ their own call centres, where staff relay emergencies to 911 officials in the appropriate city.

If callers can't speak or are too frantic to give their location, a special emergency address is kept on file as a backup. It was Comwave that proposed the solution, promising highly trained staff.

"We have gone beyond what is expected of us," Mr. Barzakay told the commission.

The CRTC imposed no regulations on the type of call centre companies would have to use. Mr. Barzakay said in an interview that Comwave could have used an American Express call centre, but opted for a home security company.

The CRTC came up with several rules, however, that Internet phone companies had to follow. They had to alert their customers to potential problems in locating the caller if 911 was dialled. This had to occur during the signup process, and warnings were to be contained in company ads and brochures.

Since an Internet phone looks like a regular phone, the CRTC required special stickers that would be affixed to phones, in the event a babysitter or houseguest did not understand the kind of phone they were using.

"We take this very seriously," CRTC director Paul Godin said in an interview about how the VoIP regulations were handled.

"If the rules are followed, the system works." But the rules were not always being followed.

The Globe investigated Comwave's sales practices. During an online signup and subsequent six-minute phone conversation with a sales agent, the subject of 911 was not raised, a violation of CRTC rules.

The call-taker asked what Internet service provider would be used, which kind of service package was needed, and described various long-distance rates; 911 was not mentioned.

"We certainly made it quite clear to them what we wanted to see," Mr. Godin said when asked about this process. But did the regulator go back to check to see if companies were following the rules? "I can't say we went back," Mr. Godin said this month.

If the CRTC had checked, it would have noticed marketing material glossed over the subject of 911, while even the smallest details — the warning stickers on phones — were out of line with what the CRTC wanted.

Documents show the CRTC wanted these alerts to say: "Warning. This is a VoIP Phone Service. 911 service may be limited or unavailable. Be prepared to give your location."

When Comwave's phone arrived in the mail, it had shortened that message to three words: "911 limitations exist."

Although the CRTC did not check to see if Comwave was following the rules, there is evidence that the regulator knew there was a problem. Among the flurry of several dozen e-mails exchanged between regulators, lawyers and other government officials in the wake of Elijah Luck's death was this internal e-mail sent May 8 to CRTC official James Ndirangu, who oversees 911 issues for the regulator.

"It just goes to show you how non-compliant these entities can be," says the message obtained by The Globe. The sender's name was redacted.

Asked why the CRTC never checked whether Internet phone companies were following the rules set out, or living up to the promises they made in 2004, Mr. Godin said, "The short answer is, we regulate by complaint, I guess.… To my knowledge we have received very few complaints."

Since Elijah Luck's death, Mr. Barzakay acknowledged in an interview that the call centre employees were not as thoroughly trained to handle emergencies as 911 dispatchers.

The CRTC and Comwave have since refused to let anyone hear the 911 call. Meanwhile, a proposal that would have fixed the Internet phone problem sat on the table for more than a year before Elijah Luck's death. It would cross-reference the address the Internet service company had on file for a person with the IP address connected to the VOIP phone call.

The solution would cost about $80-million, or as little as one cent on the average phone bill.


Even the smallest amount of oversight may have prevented the Elijah Luck tragedy. The Luck family says they didn't know their emergency address on file with Comwave had not been updated. Comwave billed them at their Calgary address for more than a year.

Mr. Barzakay has said Comwave told the family twice to update their emergency address, but the family disputes this. When asked why Comwave didn't list both addresses on its bills — the billing address and the emergency address 911 dispatchers use — Mr. Barzakay said he didn't know.

"It's the first time I've heard of that," Mr. Barzakay said. "It's such a simple idea, and yet not mandated by the commission. It would behoove us to do so. Everybody checks their bills."

The CRTC never even contemplated this small, but crucial fix.

"Had I seen Mississauga on my bill," Mr. Luck said, "I would have known something was wrong."

Comwave, in response to The Globe's investigation, has since changed its bills to show both addresses. In October, the Luck family ordered a red granite headstone for Elijah's grave. It was his birthday present.