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Protect yourself from fire

Tech, human error led to fire deaths


Coroner's report released; Says fire department's dispatch system is in shambles, recommends upgrades


While several factors contributed to the deaths of two women in a Côte des Neiges fire last March, "the delays due to the Montreal fire department's computer dispatch system considerably reduced the survival chances of the victims," a coroner ruled on Tuesday.

Coroner Cyrille Delâge said the dispatch system was a "shambles" that night, with firefighters being dispatched from downtown instead of from stations closer to the apartment on Van Horne Ave.

Emmanuelle Leclerc, 21, and Selam Fantaye, 26, died in the blaze that started in the basement laundry room. The laundry-room door had been left open, allowing thick smoke to billow up into the stairwells, making it impossible for some tenants to flee.

Almost all of the smoke detectors in the 17 units were not functioning. The two victims lived on the second floor of the three-storey building.

In his report, Delâge blames the fire department for delays that could have been avoided with better decisions.

He added that "the computerized dispatch system's decision-making process often takes precedence over personal judgment calls" by staff members.

"We live in a time where an individual's intelligence, knowledge and good judgment are not used to correct errors in a computer system that was possibly given wrong information."

The first response operator incorrectly typed in 25100V instead of 2500. But after correcting her mistake, the computer system still dispatched fire trucks from stations from downtown.

A colleague cancelled trucks from Côte des Neiges before realizing the mistake. The errors led to two fire trucks arriving with a delay of three minutes and eight seconds.

"The two dispatchers should have realized that the first address was nonsense and that the firehouses assigned to the fire could in no way reach the address within a reasonable delay," Delâge wrote.

"It is at this precise moment that a correction should have been made."

The computer system no longer dispatches fire trucks to addresses that don't exist, said Ronald Martin, president of the Association des pompiers de Montréal.

The coroner recommended that dispatchers be equipped with a hands-free telephone system, or headsets, to avoid having to hold the phone against their ear while typing in addresses.

Delâge suggested that when landlords give tenants a lease, they attach a floor plan of the building with emergency staircases clearly marked.

Although the building on Van Horne had emergency staircases, few of the tenants used them that night.

He said tenants must make sure that smoke detectors provided by their landlords are functional.

The coroner is asking the city of Montreal - and all cities across Quebec - to update their building codes so laundry rooms in apartment buildings have sprinkler systems.

The Montreal fire department did not comment on the report because it was still studying it, a spokesperson said.


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