Braidwood Commission

470 Pages·2010·2.23 MB·English

by  Braidwood Commission

WHY?

_______

The Robert Dziekanski Tragedy

BRAIDWOOD COMMISSION
ON THE DEATH OF ROBERT DZIEKANSKI

BRITISH COLUMBIA

MAY 20, 2010
Library and Archives Canada Cataloguing in Publication

Why? The Robert Dziekanski Tragedy

Braidwood Commmission on the Death of Robert Dziekanski (B.C.)

Commissioner: Thomas R. Braidwood.
ISBN 978-0-7726-6252-1

1. Dziekanski, Robert--Death and burial. 2. Police--Complaints against--
British Columbia. 3. Law enforcement--British Columbia—Equipment and
supplies. 4. Stun guns--British Columbia. 5. Governmental investigations--
British Columbia. I. Braidwood, T. R II. Title.

HV7936 E7 B73 2010 363.2'3 C2010-901002-7

BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI
May 20, 2010

The Honourable Michael De Jong, Q.C.
Attorney General of British Columbia
Room 232, Parliament Building
PO Box 9044 Stn Prov Govt
Victoria, B.C. V8W 9E2

Dear Mr. Attorney:

Braidwood Hearing and Study Commission Report into the Death of
Robert Dziekanski

I am pleased to deliver to you my report respecting the death of Robert
Dziekanski at the Vancouver International Airport on October 14, 2007,
and my recommendations respecting the handling of arriving
international passengers at the Airport, as provided for in section 28 of
the Public Inquiry Act, S.B.C. 2007, c. 9.

Yours very truly,

Thomas R. Braidwood, Q.C.
Commissioner

BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI
BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI
ROBERT DZIEKANSKI

Born: April 15, 1967, Bielawa, Poland
Died: Richmond, BC, Canada, October 14, 2007

BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI
BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI
TABLE OF CONTENTS
Letter of transmittal
Robert Dziekanski
Part 1: Executive summary and recommendations ................................ 1
A. Executive summary ...................................................................... 5
B. Summary of recommendations........................................................ 20
Part 2: The commission of inquiry .................................................. 27
A. The commission .......................................................................... 31
B. The evidentiary hearings .............................................................. 35
C. The commission’s report ............................................................... 40
Part 3: Mr. Dziekanski’s trip to Canada ............................................ 43
A. Preparation for his trip ................................................................. 47
B. Flights ...................................................................................... 50
C. Findings of fact and conclusions ...................................................... 52
Part 4: Mr. Dziekanski’s arrival in Vancouver and clearance
to enter Canada ............................................................... 53
A. Introduction............................................................................... 57
B. Vancouver International Airport arrivals layout .................................. 57
C. The Primary Inspection Line .......................................................... 61
D. His disappearance for more than five hours ....................................... 64
E. His mother’s attempts to reach him ................................................. 65
F. Secondary Customs ...................................................................... 70
G. Secondary Immigration ................................................................. 71
H. Final clearance to enter Canada ..................................................... 75
I. Findings of fact and conclusions ...................................................... 76
Part 5: Mr. Dziekanski’s activities in the International
Reception Lounge ............................................................. 81
A. Introduction............................................................................... 85
B. Initial attempts to assist Mr. Dziekanski ............................................ 85
C. The Airport’s operations and security response to calls for assistance ...... 94
BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI
TABLE OF CONTENTS
D. Findings of fact and conclusions ................................................... 112
Part 6: The response of the RCMP, Richmond Fire-Rescue, and
BC Ambulance Service ...................................................... 119
A. Introduction ............................................................................ 125
B. The RCMP officers ..................................................................... 125
C. Richmond Fire-Rescue ................................................................ 180
D. BC Ambulance Service ................................................................ 187
E. Expert testimony ...................................................................... 193
F. Findings of fact and conclusions ................................................... 231
Part 7: The cause of Mr. Dziekanski’s death ..................................... 271
A. Introduction ............................................................................ 275
B. Forensic pathologists ................................................................. 276
C. Cardiologists ............................................................................ 288
D. Emergency Department physicians ................................................ 301
E. Psychiatrists ............................................................................ 307
F. Epidemiologist .......................................................................... 313
G. Electrical engineer .................................................................... 318
H. Findings of fact and conclusions ................................................... 320
Part 8: The RCMP’s media response to Mr. Dziekanski’s death ............... 339
A. Introduction ............................................................................ 343
B. The RCMP’s public statements about the event ................................ 343
C. Findings of fact and conclusions ................................................... 356
Part 9: Recent changes at Vancouver International Airport................... 363
A. Introduction ............................................................................ 367
B. Canada Border Services Agency (CBSA) ........................................... 368
C. Vancouver Airport Authority ........................................................ 386
D. Concluding comments ................................................................ 402
Part 10: Postscript — Police investigating themselves........................... 407
A. Introduction ............................................................................ 411
B. Recent calls for reform ............................................................... 412
C. Proposals for a civilian-based investigative body ............................... 413
D. Recommendation ...................................................................... 422
BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI
TABLE OF CONTENTS
APPENDICES ............................................................................. 425
A. Terms of Reference ................................................................... 427
B. Commission Personnel ................................................................ 431
C. List of Submitters ..................................................................... 433
D. List of Witnesses ....................................................................... 435
E. Practice and Procedure Directive for Evidentiary Hearings .................. 445
FIGURES
Figure 1: International Terminal — Level 2 ................................................. 58
Figure 2: Canada Border Services — International Terminal ............................ 59
TABLES
Table 1: Chronology of events ................................................................ 321
GLOSSARY ................................................................................ 453
BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI
TABLE OF CONTENTS

BRAIDWOOD COMMISSION ON THE DEATH OF ROBERT DZIEKANSKI