Coroner's report: Dispatchers should be willing to override computers
MONTREAL - A coroner wants Montreal's fire department operators to update their computer and phone systems, and is making other recommendations in the wake of a fire that killed two Montreal women.
Emmanuelle Leclerc and Selam Fantaye died after a fire broke out in their Van Horne Ave. apartment building on March 2, 2011.
During the inquest led by Cyrille Delage, a full picture of the deadly fire including computer errors that contributed to the deaths came to light.
The fire at 2500 Van Horne Ave. was sparked by an electrical short-circuit in the basement laundry room, and thick smoke quickly filled the building's stairwells because the laundry room doors were open.
Survivors testified that they only heard a brief blast of alarms which were quickly silenced, and despite an advanced alarm system that had recently been installed, there were no battery-powered alarms in the building.
The owner of the building said the system had been inspected in 2010, but thought that problems had been corrected. That turned out not to be the case.
The second error came when people alerted by the brief alarms called 9-1-1.
The first dispatcher to take the call made a typo when putting the address into a computer system, writing the address as 25100V Van Horne Ave., and as a result the software recommended dispatching a fire crew from a distant location.
A second dispatcher who took a 9-1-1 call moments after had typed the address into the system correctly, but realizing that a co-worker was already ordering crews to the scene cancelled his instructions to send the closest fire crews.
The dispatchers realized the mistake rather quickly, but there was an estimated delay of 90 seconds before the closest fire crew was ordered to the scene.
The second and third crews to arrive were delayed by more than three minutes.Recommendations
Delage is making several recommendations in the wake of the inquest, the most important of which is to not rely on computers.
The coroner's report says fire department dispatchers should have a full and complete knowledge of fire stations in Montreal. Delage wrote the dispatchers should have realized that the computer system's initial recommendation did not make any sense, and used their own judgement to override the computer's recommendations.
The coroner also wants dispatchers to have headsets that can integrate phone calls from two lines at the same time.
The coroner is also asking the city of Montreal, and all cities across Quebec, to update their building codes so all laundry rooms in apartment buildings have sprinkler systems.
During the inquest it became apparent that some residents were not sure what to do in case of a fire. Delage is therefore recommending that lease agreements include a building evacuation plan, and that contracts include a clause showing that smoke detectors have been tested by both signatories.
The report's final recommendation is for the insurance bureau of Canada. Delage wants security companies to inform fire prevention agencies of their inspection reports, and make sure that all recommended repairs and changes actually are made.
One firefighter said that having the great benefit of computer technology does not confer an automatic advantage in all cases.
"Although you can have the greatest system that works, which includes GPS and determines the quickest truck and quickest fire station, I think it highlights the issue of the human judgment does come into play. A computer can't replace emotions can't replace all the intelligence," said Chris Ross, VP Firefighters Union.
The building's landlord has since made sure to update all of its fire safety equipment and offered personal explanations to those living within its walls, to the point that one tenant who moved in after the fire was impressed by the state of preparation.
"Everything he showed it to me, where's the fire exit, and everything and it's very safe compared to other buildings that I have seen," said tenant Greley Anisco.