Water rescue operation that killed Montreal firefighter could've claimed more lives, Quebec coroner says

The drowning death of a Montreal firefighter during a rescue operation on the St. Lawrence River in 2021 was an "avoidable tragedy" that could easily have claimed more lives, according to a scathing report from a Quebec coroner.

"There was one victim, there could've been six," coroner Ghane Kamel wrote in the report.

Pierre Lacroix, a 30-year veteran of Montreal's fire department, drowned on Oct. 17, 2021 after he and three other firefighters on a Hammerhead boat triedto rescue two boaters in distress near the Lachine Rapids.

Instead, the firefighters' boat capsized and the two boaters, who survived the events, ended up pulling some of them outof the frigid, churning water. Lacroix, caught beneath the overturned boat, did not make it.

The 55-page coroner's report, which includes 25 recommendations, was obtained by Radio-Canada's Enqute team and is expected to be made public in the coming days. A total of 36 witnesses spoke during the inquiry.

Most of therecommendations are aimed at the fire department, but the coroner did not spare the agglomeration of Montreal, the province's Public Security Ministry, the Canadian Coast Guard and Transport Canada.

Stphanie Lacroix, the victim's daughter, who took part in the coroner's proceedings last fall, welcomes the report, but adds: "It's not over."

"Now, it's written in black and white that there are a lot of flaws and a lot of things to improve," she said.

"I know it's the first step. What I don't want is for this report to sit on a shelf and gather dust. Because that would mean we took my father's story [for granted] and that he died for nothing."

Lack of training and co-ordination

Despite decades worth of experience, Lacroix had no training in whitewater navigation, meaning he was ill-equipped to deal with the emergency on the rapids that ultimately killed him.

The coroner heard that none of the firefighters involved in the operation that night and none of the officers working at the command post had been trained for water rescues.

Kamelsaid officers made decisions in good faith that night, "but unfortunately, they were not optimal," adding that the information relayed to the Canadian Coast Guard and its Maritime Rescue Sub-Centre was sometimes inaccurate.

"There were a lot of instructions, but no co-ordination," the coroner wrote.

Here are some of the other operational and equipment flaws the coroner highlighted:

• Firefighters are not equipped with locator beacons and their warning lights meant to locate themare ineffective.
• The Hammerhead boat did not have an emergency position-indicating radio beacon, or EPIRB. It also wasn't equipped with a portable waterproof very-high-frequency (VHF) radio.
• The Hammerhead was the only boat out for the rescue operation. The coroner says it should've been accompanied by at least one more.
• The coast guard team lost control of the situation, describing it as chaotic.

Despite all the risks, none of the firefighters that day thought twice about trying to rescue the boaters in distress.

One of them testifiedthe coroner that if they had been given the order to halt the operation, they would've obeyed it. That same firefighter also said, however, that had something happened to the boaters, he would have regretted leaving them there for the rest of his life.

The coroner wrote that no one from the fire department's command post gave an order to abort the operation.

Lacroix's daughter acknowledged that she feels angry about the fact her father was never properly trained.

"My father was someone who had an enormous amount of experience. He was a resourceful man," she said. "But it shouldn't have been up to him to get the necessary training. It's up to the employer to provide it to him."

Protecting firefighters from themselves

Kamel raised thenotion of creating an exclusion zone on the St. Lawrence a zone considered too dangerous for firefighters to enter.

Hubert Desgagns, a marine consultant who spent decades as a search and rescue supervisor with the Canadian Coast Guard, told the inquiry that exclusion zones can be difficult to implement.

It is difficult to know where they begin and end, Desgagns said, and boundaries might be "too close to the rapids."

Chris Ross, the president of the Montreal firefighters' union, said such a zone goes against the principles of firefighting.

"Establishing a forbidden zone is like telling people on the third floor of a burning building that we can't go get them because we're not allowed to go higher than the second floor."

"This image alone convinced me that it would be unrealistic to believe that imaginary boundaries in the St. Lawrence River would be a barrier to the sense of duty of firefighters whose mission, most notably, is to save lives," Kamel wrote.

Kamel concludes that firefighters need to be better trained for marine emergencies, as opposed to being told where not to go.

"To think a firefighter won't risk it all despite some imaginary boundary is wishful thinking," she wrote.

The coronersaid the fire department should ensure that its training program for water rescues meets "the highest quality standards" as quickly as possible and be applicable towhitewater scenarios.

She also saidthe training shouldbe standardized and delivered to all firefighters. In her report, Kamel lamented the fact that some firefighters would get training and others wouldn't, depending on who they worked with and theskills their colleagues had.

Kamel noted that Benoit Martel, a former Montreal fire chief, had warned management as early as 2013 that its training protocols were inadequate. She saidthe problems he flagged persist to this day.

"I hope that now, we'll take water rescues more seriously," Martel told Radio-Canada in an interview. "I hope that we'll deal with it and address the coroner's recommendations."

On Friday, the city of Montreal said it has set up a committee to review its water rescue training programs and make sure firefighters have access to "tools and work methods that minimize risk."

"This committee will include the coroner's recommendations in its reflections and suggestions," the city's statement reads.

The city also said that prior to Lacroix's death, the fire department was already in the process of purchasing 12 "high performance" boats designed for water rescues with "state-of-the-art" equipment.

The boats will gradually becomeavailable to firefighters as of next month, the city said.

Quebec has no boat rescue certification program

According to the coroner, the Quebec government needs to revise the rules and regulations for firefighting departments since they haven't been updated since 2004 and don't include specific details about water rescues.

She also said the province needs to establish a training program for boat rescues.

The coroner also recommends better signage to warn people about the dangers of the rapids.

She is calling for cities in the agglomeration of Montreal to ensure that there are warning signs near the water just east of the Mercier Bridge and around boating docks in Lachine.

Kamel also said public boating docks around the island should be identified and safety signs should be put up where it is deemed necessary.