A. INTRODUCTION

Most of this report focuses on the events of October 13 and 14, 2007, that culminated in Mr. Dziekanski’s death. However, the Terms of Reference also include a directive “to make recommendations the commissioner considers necessary and appropriate.”

Although unlimited on its face, I have interpreted this directive in light of the overall mandate of this hearing and study commission, which is to inquire into the events and circumstances of and relating to Mr. Dziekanski’s death, not limited to the actual cause of death.

Since one of the accepted purposes of a public inquiry is to prevent the recurrence of a tragedy, this instruction to make recommendations must, at a minimum, focus on improvements respecting the handling of, and services provided to, arriving international passengers at the Vancouver International Airport, especially those who do not speak English. Consequently, I have concluded that I have been instructed to inquire into the policies, procedures, and practices of those agencies at the Airport that deal with, or provide services to, arriving international passengers, specifically the Canada Border Services Agency (including Immigration and Customs) and the Vancouver Airport Authority.

In May 2009 I heard the evidence, voluntarily and not under summons, of two policy experts from the Canada Border Services Agency and one policy expert from the Vancouver Airport Authority. They explained what policies, practices, and procedures were in place in October 2007, and what changes have been implemented since then.^¹ In this part, I have relied primarily on their evidence and on the printed materials they filed.

During the evidentiary hearings I also heard evidence about three other public agencies — Richmond Fire-Rescue, the BC Ambulance Service, and E-Comm (which provides emergency dispatch services for several Lower Mainland police and fire agencies). Earlier in this report, I summarized the activities of personnel from these agencies who responded to the Dziekanski incident at the Airport. However, I do not intend to deal with those agencies in this part — in my view, an in-depth review of these agencies’ policies and procedures would be beyond my mandate.

B. CANADA BORDER SERVICES AGENCY (CBSA)

1. Introduction

I am aware of the limited constitutional capacity of a provincially appointed commission of inquiry to inquire into and make recommendations respecting the internal management and administration of federally regulated agencies, such as the Canada Border Services Agency.

At the same time, it is important to remember that CBSA is often the first government agency that arriving international passengers, both tourists and immigrants, encounter. As such, CBSA is more than just an enforcement agency — it is the face of our country and of our province.

The Government of the Province of British Columbia has an interest in seeking improvements in the services that are provided to newcomers arriving here, and it is in keeping with that interest that I have undertaken this analysis of the Canada Border Services Agency.

Out of respect for my limited jurisdiction, I have attached several qualifications to the recommendations that follow. First, I limit their application to the Vancouver International Airport, as that is the only airport I have examined. If my recommendations find favour with government, it may be prudent to implement them here first, on a pilot basis.

Second, it would not be appropriate for me to direct my recommendations to the federal minister. According to convention, I have directed my recommendations to the provincial Attorney General. If the Attorney General endorses my recommendations, I invite him to urge the federal Minister of Public Safety to act on them.

I note that in his closing written submissions, counsel for the Government of Canada stated:

Canada and its agencies are first and foremost interested in the safety and security of Canadians. Therefore, Canada will carefully review the recommendations the Commissioner considers necessary and appropriate
(p. 3).

2. Policy witnesses

CBSA was formed in 2003. It was an amalgamation of three separate entities: the Customs Branch of the former Canada Customs and Revenue Agency, the enforcement arm of Citizenship and Immigration Canada, and the frontline inspection services of Agriculture Canada. It reports, through its president, to the Minister of Public Safety.

I heard the evidence of two senior CBSA officials. Brian Hilton is a senior policy advisor with the Arming Division in the Operations Branch in Ottawa, and Binder Kooner is the chief of Passenger Operations at the Vancouver International Airport. CBSA also provided documentary materials regarding training, policies, and the interpretation of legislation.

During the evidentiary hearings I had also heard the testimony of several CBSA Border Services officers, who provided insight into how CBSA policies were implemented on a day-to-day basis, and particularly during Mr. Dziekanski’s time in the Customs Hall. However, these witnesses were not policy experts, and I have not relied on their testimony in the formulation of my recommendations.

In this section I will examine four CBSA policies and practices that are relevant to the manner in which Mr. Dziekanski was dealt with during his prolonged stay in the Customs Hall:

processing passengers;
security;
communications between arriving passengers and greeters awaiting them; and
interpretation services.

3. Processing passengers

As I discussed in Part 4, every arriving international passenger comes down an escalator into the Customs Hall. If the passenger has not completed the Customs Declaration Card during the flight, the passenger does so here. The passenger is directed to CBSA’s Primary Inspection Line, where a Border Services officer inspects the Customs Declaration Card, and questions the passenger if further information is required. If no Customs or Immigration concerns arise, the passenger is released, retrieves any checked baggage, and exits through the Point into the public area of the Airport, after surrendering the Customs Declaration Card.

If the Border Services officer thinks the passenger is suspicious, or if the passenger’s circumstances require a mandatory referral to Secondary Customs or Immigration, then the Border Services officer makes a handwritten notation on the passenger’s Customs Declaration Card, and the passenger must go to the appropriate secondary area or areas. Border Services Officer Monica Kullar told me that it is mandatory to refer a passenger who does not speak English or French (such as Mr. Dziekanski) to both Secondary Customs and Secondary Immigration.^² Mr. Hilton informed me that before any passenger is allowed to leave the Customs Hall, a Border Services officer at the Point checks the passenger’s Customs Declaration Card to ensure that he or she has been cleared by Secondary Customs and/or Secondary Immigration.

Because Mr. Dziekanski disappeared within the Customs Hall area for five-and-a-quarter hours, I was interested to learn what steps CBSA takes to facilitate its processing of arriving international passengers. I was told that there are two database systems, which I will discuss in turn.

a. Integrated Primary Inspection Line Database

This database is used at the Primary Inspection Line and at Secondary Customs. At the Primary Inspection Line, a Border Services officer swipes a passenger’s passport or other documentation through an electronic scanner, entering it into this database. If the officer refers the traveller to Secondary Customs, the officer will enter the reason for the referral into the database. When the referred traveller goes to Secondary Customs, a Border Services officer will enter the traveller’s name into this database again, and the information entered at the Primary Inspection Line will appear.

This database can also be used to check if a passenger has crossed the Primary Inspection Line. However, the database does not include an alarm or warning system to notify a Border Services officer if a referred passenger fails to attend at Secondary Customs within a specified period of time. I was told that the computer system is designed for the processing of travellers, not for tracking passengers’ progress through the Customs Hall.

Border Services officers in Secondary Customs are supposed to make a computer notation to indicate that they have completed processing a passenger. Thus, officers should be able to rely on the Integrated Primary Inspection Line Database to indicate whether a passenger has left Secondary Customs. However, Mr. Kooner told me that many officers do not make this notation immediately after they have finished with a passenger, waiting until the end of their shift to do so.

b. Field Operations Support System

This is the main computer system used for documenting immigration matters at Secondary Immigration. It also contains information about new immigrants, for example, the information about Mr. Dziekanski’s sponsor (his mother) and her name and phone number. However, Mr. Hilton told me that this database does not record whether a passenger has crossed the Primary Inspection Line. That information is recorded only in the Integrated Primary Inspection Line Database, which officers at Secondary Immigration do not have access to.

Conclusions and recommendations

It is beyond my mandate to review or make recommendations about CBSA’s passenger information databases generally, and I will limit my comments to those aspects of the database systems in use at the Vancouver International Airport that impacted on
Mr. Dziekanski.

It is appalling that Mr. Dziekanski could have been cleared through CBSA’s Primary Inspection Line efficiently, only to disappear within the cavernous Customs Hall for over five hours. No one individual appears to have been at fault for this, but CBSA’s passenger tracking capability is woefully inadequate:

CBSA still maintains two separate database systems, presumably a holdover from when Customs and Immigration were separate agencies. The net result is that Border Services officers in Secondary Customs can find out whether an arriving international passenger has cleared the Primary Inspection Line, but an officer in Secondary Immigration cannot.
CBSA does not have the capacity to monitor a passenger’s progress through the Customs Hall. Although data about each arriving passenger is entered into the Integrated Primary Inspection Line Database before the passenger clears the Primary Inspection Line, the system appears to break down at that point. There is no single database that records basic information such as whether the passenger must also go to Secondary Customs and/or Secondary Immigration, or records when the passenger arrives at and clears those secondary locations and finally passes through the Point. One database records referrals to Secondary Customs, but the other database does not record referrals to Secondary Immigration.
CBSA offers inadequate assistance to travellers about where they must go or how to get there, especially travellers such as Mr. Dziekanski, who speak neither of Canada’s official languages and are unfamiliar with air travel and airports. The officer at the Primary Inspection Line makes handwritten coded notations on the passenger’s Customs Declaration Card, which the passenger cannot decipher, and tells the passenger, often in a language the passenger cannot understand, where to go. At the least, such travellers should be provided with a floor plan of the Customs Hall, identifying where Secondary Customs and Secondary Immigration are, which one or ones they must go to, and how to get there.
CBSA makes no effort to track a passenger’s progress through the Customs Hall, and to alert officers when the passenger does not reach their next “destination” within a predetermined period of time. It appears that undue reliance is placed on handwritten coded notations scribbled onto the passenger’s Customs Declaration Card — an anachronism in our digital age of electronic scanners and bar codes.

Recommendation 1

I recommend that the Attorney General urge the federal Minister of Public Safety:

To require that Border Services officers at Vancouver International Airport’s Primary Inspection Line explain to each arriving international passenger, in a manner the passenger understands, whether the passenger is required to proceed to Secondary Customs and/or Secondary Immigration and, if so, how to get there.
To implement a single integrated database system for international passengers arriving at the Vancouver International Airport that:

creates a file for each passenger on arrival at the Primary Inspection Line;
records the time when the passenger clears the Primary Inspection Line;
records whether the passenger is required to proceed to Secondary Customs and/or Secondary Immigration;
records the time by which the passenger is required to reach each Secondary location;
records the time when the passenger actually reaches, and subsequently clears, each Secondary location and the Point; and
issues an alert to all Border Services officers if a passenger does not reach the next Secondary location within a predetermined period of time.

To impose a positive duty on specified Border Services officers to page and actively search for any passenger for whom an alert has been issued under the immediately preceding paragraph.
Until the single integrated database system recommended above is in operation, to ensure that all Border Services officers at the Vancouver International Airport have prompt and easy access to both the Integrated Primary Inspection Line Database and the Field Operations Support System.

4. Security in the Customs Hall

Mr. Hilton explained to me that the Vancouver Airport Authority owns the Customs Hall area and that CBSA is the tenant. As tenant, CBSA controls who enters the Customs Hall area. However, if a medical emergency or a disturbance arises, other agencies will respond, such as the Airport’s Emergency Response Service, the
BC Ambulance Service, the Airport’s security officials, or the RCMP.

I was interested to learn what steps CBSA takes to identify and assist arriving international passengers who get “lost” or spend an inordinate amount of time in the Customs Hall area.

a. “Rovers”

Mr. Hilton told me that CBSA assigns “Rovers” to move throughout the Airport, including the Customs Hall area, to identify individuals who may be involved in the unlawful importation or exportation of goods, including illicit drugs. Their main purpose is to “engage with as many people as possible, make a quick determination as to whether they’re outside ... the realm of the normal traveller, and then try to elevate the level of questions and make a decision whether they need to inspect the person further.”^³

Rovers are also on the lookout for arriving passengers who attempt to destroy their travel documents (so that Border Services officers cannot determine their country of origin or the flight they arrived on), and then claim refugee status. Rovers are not necessarily on duty at all times — it depends on the volume of passengers moving through the Customs Hall area.

It is clear that rovers perform an enforcement function, as distinct from a security or customer care function. For example, since CBSA does not have a policy prohibiting a passenger from remaining in the Customs Hall for a long period of time, a rover would not necessarily be concerned about a passenger who has been there for a long time. Both Mr. Hilton and Mr. Kooner told me that if a traveller were seen sitting in the Customs Hall, not causing a disturbance or attracting attention, the rover would not be expected to investigate.

b. Surveillance cameras

In October 2007, there were 13 cameras in the Customs Hall area, with limited coverage. According to Mr. Kooner, there was modest coverage in Secondary Customs, but no coverage in the pre-Primary Inspection Line area, in the Secondary Immigration area, or in the washrooms. One Border Services officer, Trevor Gross, testified that these cameras were not necessarily monitored routinely. Mr. Kooner told me that since then, the number of cameras has increased from 13 to 97, but I understand that there is currently no policy respecting the use or monitoring of these cameras.

c. Instruction to be more vigilant

Since October 2007, all Border Services officers have been instructed to be more vigilant in ensuring that travellers move through the Customs Hall in a timely fashion. They have also been told that they may approach a passenger who has been in the Customs Hall for a prolonged period and inquire about that person’s reason for being there.

Conclusions

From this evidence, I conclude that CBSA does not place a high priority on instituting programs or procedures to identify and assist arriving international passengers (like Mr. Dziekanski) who get “lost” or spend an inordinate amount of time in the Customs Hall area. While it is a positive improvement that officers are now instructed to be more vigilant to ensure that travellers move through the Customs Hall in a timely fashion, it would have been preferable to impose a mandatory duty on officers to intervene and offer assistance to travellers, rather than opting for a permissive “may approach” policy.

As I will discuss later in this part, the Vancouver Airport Authority has instituted its own program to identify and assist arriving international passengers who get “lost” or spend an inordinate amount of time in the Customs Hall area. This is a needed, and welcome, improvement, and because the Airport Authority has responded to this need, I decline to make a recommendation that CBSA do so.

5. Communication between arriving passengers and greeters awaiting them

In Part 4, I reviewed the repeated attempts by Mr. Dziekanski’s mother and
Mr. Hutchinson to find out from Border Services officers whether Mr. Dziekanski had arrived, only to be told that they could not disclose that information for privacy reasons.

Mr. Hilton told me that two pieces of federal legislation apply in these circumstances:

The Customs Act, s. 107 prohibits CBSA from disclosing any information that it collects about a traveller, although there are several exceptions to this general rule, including that information can be released with the traveller’s consent.
The Privacy Act contains an overarching prohibition on the use and disclosure of personal information, except for the purpose for which it was gathered or except with the consent of the individual.

CBSA has interpreted this legislation to mean that Border Services officers may not tell an inquiring greeter whether a traveller is present in the Customs Hall, except with the traveller’s consent. Mr. Hilton explained that on a national basis, CBSA has no policies specifically dealing with communications between passengers and greeters, even when the greeters are family members. However, Border Services officers are trained that they generally cannot communicate to anyone any information about an individual with whom they have dealt, without that individual’s consent. They are also taught the conditions under which information about an individual may be disclosed and the uses to which it may be put. Even though the Field Operation Support System, one of the computer databases discussed earlier, contained the information that
Mr. Dziekanski’s mother was his sponsor, with her name and phone number, Border Services officers would not have been authorized to discuss any information about
Mr. Dziekanski with her before they dealt with him and obtained his consent.

Mr. Kooner described what happened at the Vancouver International Airport in October 2007. The CBSA office regularly received calls from greeters, attempting to locate a passenger. When a call was received about a new immigrant, a Border Services officer would look for the traveller in the Secondary Immigration area. If the traveller was present, the officer would speak to him or her, ask for consent to release the information about the traveller’s whereabouts, and then pass the information on to the greeter. If the new immigrant was not present, there was no expectation that a Border Services officer would attempt to determine whether the individual had crossed the Primary Inspection Line or was in the Customs Hall.^⁴

Mr. Kooner told me that, since the Dziekanski incident, CBSA at Vancouver International Airport has developed a new standard operating procedure that encourages Border Services officers to look for a traveller if more than two hours have passed since the traveller’s flight arrived, and if there are extenuating circumstances:^⁵

Section 1 instructs Border Services officers to verify certain information with the greeter making the request, including the purpose of the trip, whether the traveller got on the flight, the flight number and arrival time, and if the traveller would require additional assistance. This section includes possible reasons a traveller might require additional assistance, such as if the traveller is elderly, or has medical requirements, or a physical disability.
Section 2 directs Border Services officers to advise the greeter that routine processing can be lengthy, and to estimate a possible waiting time. This section also suggests that “[i]f sufficient time (often two or more hours) has elapsed since the arrival of the traveller’s flight and there are extenuating circumstances such as those noted above, the [Border Services officer] may contact a superintendent to assist in locating the traveller.”
Section 3 states that if “sufficient time has elapsed since the flight arrival but no extenuating circumstances exist, the [Border Services officer] may still contact a superintendent” and make inquiries regarding “traffic volumes and processing times.”
Section 4 relates to recently arrived flights, and encourages Border Services officers to tell inquiring greeters that they can check for messages from arriving travellers on a message board in the International Arrivals area.

The standard operating procedure concludes with the statement that Border Services officers “are encouraged to exercise discretion and common sense when the circumstances warrant further approaches (e.g., emergencies and exigent circumstances).” However, definitions or examples of “emergencies” and “exigent circumstances” are not provided.

It is my understanding that CBSA’s new standard operating procedure was implemented, at least in part, as a response to perceived inadequacies arising out of the Dziekanski incident. That being so, there are several aspects of the new policy that warrant comment:

Tracking the passenger’s progress — it does not require that the officer do what, in my view, would be an obvious first step — ascertain whether the passenger has crossed the Primary Inspection Line. I accept that the Customs Act and the Privacy Act may impose limitations on what information a Border Services officer may convey to a greeter, but determining whether the passenger has reached the Customs Hall is an essential first step in deciding how to respond to a greeter’s enquiry. For example, if the officer determines that the passenger has crossed the Primary Inspection Line, then the officer would certainly not suggest that the greeter go home. Depending on the time since the passenger’s flight arrival, it might be appropriate to conduct a search of the Customs Hall area.
Status of a sponsor — in the case of an arriving immigrant, the new policy gives no recognition to the special status of that passenger’s sponsor. It does not require a Border Services officer to ask the relationship between the greeter and the passenger, and it does not give any preferential treatment to the sponsor of a new immigrant. Sponsors have a highly significant legal role in the immigration process — by becoming the sponsor of a new immigrant, he or she has accepted legal responsibility for the new immigrant’s financial well-being. This role should entitle the sponsor to special consideration when making an enquiry about an arriving immigrant. If CBSA is concerned about obtaining the new immigrant’s consent for releasing the information that the individual has arrived, I see no reason why this consent cannot be obtained as a matter of course during the immigration process.
Mr. Hilton told me that most of the processing for a new immigrant’s landing is done overseas. It seems that adding this one additional step — obtaining the new immigrant’s consent to tell a waiting sponsor when he or she arrives — could further simplify and improve the new immigrant’s experience landing in Canada.
Paging — the new policy does not require that the officer page the arriving passenger to receive a message. Mr. Hilton told me that he was not aware of any security concerns in doing so. In addition, Mr. Kooner told me that Border Services officers have access to paging facilities in the Customs Hall, and that there have been no changes to the paging system since the incident.
Extenuating circumstances — the new policy focuses on “extenuating circumstances,” but does not define that term. If it is meant to refer to the elderly or those with a medical requirement or physical disability it would not extend to people like Mr. Dziekanski — a confused, first-time international traveller who spoke neither of Canada’s official languages.
Passive — the new policy is drafted passively (e.g., the officer may contact a superintendent), rather than imposing a mandatory duty
to do so.
Confusing — Section 3 is confusing when read in conjunction with Section 2, because it appears to suggest that where there are no extenuating circumstances, a Border Services officer may only make specific types of enquiries. Some Border Services officers might interpret this to mean that they should not attempt to locate a passenger unless certain extenuating circumstances are present.

Conclusions and recommendations

If CBSA implements the single integrated database system I recommended earlier in this part, it should reduce the incidence of arriving international passengers getting “lost” or spending an inordinate amount of time in the Customs Hall. In addition, the Vancouver Airport Authority’s new Customs Hall Rover position should assist in identifying and helping passengers who appear lost or confused.

Nevertheless, there will still be greeters who contact CBSA for assistance in finding and getting word to arriving passengers. While CBSA’s new standard operating procedure is an improvement, more can and should be done to assist enquiring greeters.

Recommendation 2

I recommend that the Attorney General urge the appropriate federal minister or ministers:

To implement a policy of inviting each prospective immigrant, when applying overseas for immigrant status, to consent in advance to their sponsor being informed when they do enter Canada.
To impose a duty on a Border Services officer at the Vancouver International Airport, who receives an enquiry from a greeter about an arriving international passenger:

To determine whether the passenger has crossed the Primary Inspection Line.
If the passenger has crossed the Primary Inspection Line more than two hours ago, to page the passenger and to record in the passenger’s file in the proposed single database system the particulars of the greeter, the greeter’s relationship to the passenger, any special assistance that the passenger may require and, where appropriate, a message from the greeter to the passenger; and
If the passenger has not crossed the Primary Inspection Line, to make a note in the proposed single database system containing similar information.

To impose a duty on a Border Services officer at the Vancouver International Airport, who deals with an arriving international passenger at Secondary Customs or Secondary Immigration, to inform the passenger:

of the details of any enquiry by a greeter that is recorded in the proposed single database system; and
how the passenger may communicate with the greeter.

To install in the Customs Hall one or more closed-circuit TV monitors showing the greeters who are waiting in the public Meeting Area of the International Terminal Building, unless the minister is satisfied that there are legitimate security reasons for not doing so.

6. Interpretation services

a. Introduction

As discussed earlier in this report, Mr. Dziekanski had access to printed materials in Polish when he completed the Customs Declaration Card prior to approaching the Primary Inspection Line. Thereafter, when dealing with CBSA officials at the Primary Inspection Line, at Secondary Customs, at Secondary Immigration, and at the Point, he had no access to a Polish interpreter or to printed materials in Polish. Communication was limited to showing officials his papers, to hand signals and gestures, and, in the case of Border Services Officer Chapin, to a rudimentary knowledge of a few Polish words.

I was interested to learn whether the treatment Mr. Dziekanski received was typical of arriving international passengers who speak neither of Canada’s official languages and, if so, whether any significant changes have been introduced since his death.

b. The national picture

Mr. Hilton told me that Border Services officers interact, on a daily basis, with passengers who do not speak English or French. However, it is not mandatory for officers to use an interpreter while processing such a passenger, unless there is a question of that person’s inadmissibility to enter Canada, such as a possible deportation. Outside of these circumstances, Border Services officers are trained to use “coping mechanisms” to deal with a language barrier.

CBSA allows its officers to process travellers at Secondary Customs based on inspection alone, and at Secondary Immigration based on documentation alone. In particular, there is no requirement for an officer to call for an interpreter while processing a new permanent resident, because admissibility issues have already been dealt with overseas.

Having said that, CBSA does not prohibit Border Services officers from calling an interpreter. If a passenger appears to be experiencing difficulty due to a language barrier, an officer may attempt to call an interpreter, but will avoid delaying the traveller needlessly. There has been no change to CBSA’s national policies regarding interpreters since October 2007.

Mr. Hilton did not have detailed knowledge concerning the interpretation resources available at specific airports. He did tell me that at most ports of entry, CBSA keeps a multilingual leaflet to assist passengers who do not speak English or French with filling out the Customs Declaration Card. Mr. Dziekanski used this leaflet in completing his card.

c. The situation at the Vancouver International Airport

Mr. Kooner told me that officers at Vancouver International Airport have several options for contacting an interpreter. The following services were available in 2007, as they are today:

CBSA employs interpreters on site for several languages.
CBSA maintains a list of staff members who speak different languages and can be contacted to assist.
Officers can access a database of interpreters, who can be contacted individually by telephone.
Officers have access to a 24-hour interpreter phone line.
Officers are allowed to access any interpretation services provided by the Airport, and may also request assistance from airline personnel.

Notwithstanding this impressive list of options, the Border Services officers who dealt with Mr. Dziekanski did not call an interpreter to assist, for various reasons. For example, when Officer Van Agteren accessed the interpreter database, she discovered that all of the Polish interpreters were either unavailable or did not wish to be contacted for an interview of less than two hours. Officer Purewal, an officer at Secondary Immigration, testified that she did not know of a phone that had interpreter access. Supervisory Officer Currie, also at Secondary Immigration, was unaware of the 24-hour interpreter phone line and did not know about CBSA’s list of staff members who speak other languages.

I also heard evidence that interpretation is not routinely provided in circumstances where the arriving passenger has a need to understand what the officer is communicating. For example:

Officer Kullar told me that an officer at the Primary Inspection Line who is unable to communicate with a non-resident must refer that passenger to both Secondary Customs and Secondary Immigration. But there appears to be no system in place to ensure that the passenger understands where he or she must go, why, or how to get there.
When a foreign-language-speaking passenger reaches a secondary location, it is unusual for an interpreter to be used. Officer Bharya told me that an interpreter is not usually called at Secondary Customs if informal sign language appears effective. Officer Purewal testified that calling an interpreter to Secondary Immigration to assist by telephone occurs very infrequently.
Officer Chapin described his interaction with Mr. Dziekanski at Secondary Immigration. He had a duty to obtain answers from
Mr. Dziekanski to three specific questions before he could be processed as a landed immigrant: (1) Are you married? (2) Do you have any children? (3) Have you ever been arrested? Rather than resorting to an interpreter, Mr. Chapin relied on his rudimentary understanding of a few Polish words to get the answers he needed. He pointed to his ring finger and said, “My love” in Polish to ask Mr. Dziekanski if he was married. He made a gesture for holding a small baby and said, “Little family” in Polish to ask if Mr. Dziekanski had children. He said, “Police problem?” in Polish to ask if Mr. Dziekanski had been charged with any criminal offences before his arrival in Canada. I commend Mr. Chapin for using his best efforts to communicate with Mr. Dziekanski, but this scenario, when viewed dispassionately, borders on the farcical. It is not enough to answer that landed immigrants are considered “low risk” because the majority of processing has been done overseas. If CBSA officers are required to get proper answers to these questions before admitting a landed immigrant to Canada, surely CBSA has a duty to ensure that officers have ready access to the tools they need in order to get accurate and reliable information from passengers. This would not necessarily require the services of an interpreter. CBSA officers in Secondary Immigration could be provided with printed forms in numerous languages (similar to the multilingual guides used for completion of the Customs Declaration Card) that pose the three mandatory questions, with “Yes” and “No” boxes for the immigrant to complete.

CBSA’s People Processing Manual has a chapter on “Awareness Issues” and a list of guidelines and procedures related to language issues under the heading “Effective Cross-Cultural Communication.” One procedure states that travellers who do not speak English or French should be referred to secondary areas “for the services of an interpreter.”^⁶ This procedure goes to the heart of showing cultural sensitivity to a newly arrived person, by ensuring that the individual can receive assistance that he or she can understand.

d. Recent changes

CBSA has implemented two changes at the Vancouver International Airport since October 2007. First, it has updated its list of interpreters by removing people who are no longer available and by adding new people to the list. Second, the list of CBSA staff who can speak other languages has also been updated.

Conclusions and recommendations

Several realities emerge from this review. First, many of the CBSA officers who dealt with Mr. Dziekanski appeared to be unaware of some of the interpretation services that were apparently available to assist them when dealing with travellers who speak neither of Canada’s official languages. Nothing I heard suggests that this has changed.

Second, there appears to be a disconnect between the laudable language of the People Processing Manual and the day-to-day practice. The manual promotes the use of interpreters, but according to Mr. Hilton, officers are trained to use “coping mechanisms” to deal with language barriers.

Third, this disconnect may result from a well-intentioned desire to move a massive number of arriving international passengers through the Customs Hall as efficiently as possible. It appears to have led to a mindset among CBSA officers of getting by without resort to interpreters whenever possible. But this goal of efficiency comes at a cost:

People like Mr. Dziekanski have no way of communicating effectively with the officers, do not understand what is required of them, do not know where to go or why, and are largely left to their own devices. It is a singularly unimpressive way to welcome foreigners to our country, especially new immigrants.
CBSA officers’ resorting to “coping mechanisms” (such as Mr. Chapin’s well-intentioned exchange with Mr. Dziekanski) means that CBSA is not getting accurate and reliable information from arriving passengers on presumably important matters.

At a more elementary human level, greater use of interpretation services for arriving international passengers could make an enormous difference to their experience. In Mr. Dziekanski’s case, for example, giving him a printed form in Polish when he crossed the Primary Inspection Line, telling him that he had to go to Secondary Customs and then Secondary Immigration, and how to get to each, may well have prevented his five-and-a-quarter-hour disappearance in the Customs Hall. When he eventually reached Secondary Immigration in a distressed state, a Polish interpreter could have explained to him the processing of his immigration papers, asked him why he had been in the Customs Hall so long, advised him that his mother had been at the Airport and had called looking for him, and that she might have driven home to Kamloops, but that they were calling her at home to let her know that he was still there. The interpreter could have given him some advice about where he could go in the Airport in the middle of the night until she came back. We know how
Mr. Dziekanski was treated, but we do not know how many others have experienced similarly unsatisfactory service.

Recommendation 3

I recommend that the Attorney General urge the federal Minister of Public Safety to ensure that:

CBSA officers at the Vancouver International Airport receive training, regularly updated, on what interpreter services are available to them and to arriving international passengers, and how to access such services.
CBSA provide its officers at the Vancouver International Airport with adequate resources (e.g., interpreter services, printed multilingual forms, etc.) to ensure that arriving international passengers:

know where they have to go within the Customs Hall, and how to get there;
know what is being asked of them, when an officer is required to seek specific information, and are able to communicate such information to the officer;
know if a greeter has attempted to contact them; and
are assisted in their own language, if they appear to be confused or distressed.

C. VANCOUVER AIRPORT AUTHORITY

1. Introduction

Vancouver International Airport is operated by the Vancouver Airport Authority, a non-profit corporation that reports to a broadly based board of directors. Board members are appointed by nominating entities, including the City of Richmond, the City of Vancouver, Metro Vancouver, the Government of Canada, the Vancouver Board of Trade, and three professional governing bodies.

During daytime hours, the Airport has 60–65 flight arrivals and departures each hour. On an average day, 12,000 passengers go through the International Arrivals process. At peak times, that volume may reach 1,500–2,000 passengers each hour.

2. Policy witness

The Vancouver Airport Authority tendered Don Ehrenholz, currently vice-president of Operations, to testify respecting Airport policies and procedures, and to describe the Airport Authority’s comprehensive review undertaken following Mr. Dziekanski’s death. In addition, the Airport Authority also provided extensive documentary materials dealing with training, policies, and emergency procedures, as well as several reports prepared for the Airport Authority by outside consultants.

Earlier in this report I made reference to the testimony of numerous Airport Authority employees or contractors, many of who had some interaction with Mr. Dziekanski on October 13 or 14, 2007. I will refer to some of these witnesses’ testimony in this part, but on matters of Airport Authority policy, I will rely on the testimony of
Mr. Ehrenholz and the materials tendered through him.

3. The Airport Authority’s internal review following Mr. Dziekanski’s death

Mr. Ehrenholz told me that, prior to October 2007, the Vancouver Airport Authority had never seen a situation similar to the one involving Mr. Dziekanski. In order to ensure that such a situation would never occur again, the Airport Authority appointed Mr. Ehrenholz in November 2007 to lead an internal task force. His mandate was to undertake a review process of the Airport’s procedures, make recommendations for change, and implement the recommendations after approval from the board of directors.

Mr. Ehrenholz and the internal task force spent six weeks reviewing every aspect of Mr. Dziekanski’s and his greeters’ experiences at the Airport, to ascertain what happened and to identify areas where changes could be recommended. They also conducted town hall meetings to provide an opportunity for employees to suggest changes for improving the Airport, and they consulted with various external agencies including the City of Richmond, the Canada Border Services Agency, the Canadian Air Transport Security Administration, the United States Customs and Border Protection, and several other agencies that operate at the Airport.

The ultimate goal of Mr. Ehrenholz’s internal task force was to review and change the Airport’s systems so that they would “deal with the needs of every customer, no matter what the time of day, no matter whether they are in the areas controlled by the [Vancouver Airport] Authority, the Customs Hall controlled by the federal government, or in spaces occupied by the airlines.”^⁷

On December 7, 2007, the Vancouver Airport Authority announced 33 changes that were planned for the Airport. Some of these changes had already come into effect, while others were scheduled for future implementation.^⁸ At the time Mr. Ehrenholz testified in May 2009, all 33 changes had been fully implemented.

Mr. Ehrenholz also told me that the Vancouver Airport Authority retained an external consultant, InterVISTAS, to review its customer service processes with a view to comparing Vancouver International Airport to other airports, both domestic and international. In particular, the Airport Authority wanted to determine if the Airport was lacking in certain customer care areas, and to obtain information regarding best practices at other airports. In InterVISTAS’ first report, released in January 2008, Vancouver International Airport was ranked as having best practices in some categories, while other airports received higher rankings in some other categories. After Mr. Ehrenholz’s internal task force had implemented a significant number of changes, InterVISTAS conducted a second review to audit those changes. This update report, released on March 13, 2009, verified the changes, and reported that Vancouver International Airport now had the best practices in several additional areas.

I do not propose to review, in detail, the 33 changes implemented by the Airport Authority, or the findings of the two InterVISTAS reports. Rather, I will focus on the following four general areas, to assess the adequacy of the Airport Authority’s response to the Dziekanski incident:

customer care for passengers and greeters;
communication between arriving passengers and greeters;
safety and security; and
emergency and medical response.

4. Customer care for passengers and greeters

Earlier in this report, I documented how Mr. Dziekanski disappeared from view within the Customs Hall for five-and-a-quarter hours how his mother and Mr. Hutchinson repeatedly tried, unsuccessfully, to get word to her son and how no one provided
Mr. Dziekanski with access to an interpreter when he was in the International Reception Lounge. I was interested to learn what steps the Vancouver Airport Authority has taken since then to improve customer care services to arriving international passengers and to greeters.

Mr. Ehrenholz told me that there are thousands of people working at the Airport. Only approximately 400 of these are direct employees of the Airport Authority. Many others are directly employed by airlines or government agencies, and still others are employees of private firms such as Marquise and Securiguard, which contract with the Airport Authority to provide customer service and security services respectively. For example, in October 2007, Marquise employees included the visitor/information counsellor at the BC Visitor Centre, the customer service agent at the Customer Information booth in the Departures area, and the customer service agents in the pre-Primary Inspection Line area of the Customs Hall.

Mr. Ehrenholz told me about the improvements to customer care that the Airport Authority has introduced, which I will summarize.

a. New training program

One of the Airport Authority’s early changes was to create a comprehensive new training program, with the intent to encourage everyone who works at the Airport to be more proactive in seeking out people who need assistance. The training also teaches that if an employee is unable to assist a passenger, he or she should take that passenger to an Airport customer service agent to receive the assistance that passenger needs.

Nearly all Airport Authority employees have received the new training, and in addition, a large percentage of contracted employees, including Marquise, Securiguard, and the baggage cart retrievers, have been trained. The Airport has also run a course for Canada Border Services Agency officers. When Mr. Ehrenholz testified in May 2009, the Airport Authority was also running courses for U.S. Customs agents. It was developing courses for employees of the Canadian Air Transport Security Administration and online courses to train airline customer service agents.

b. Customer care cards

The Airport Authority discovered that employees would begin to forget, within three to six months, basic information they had been taught during the new training program. To address this issue, the Airport Authority is now providing Customer Care Cards to approximately 70 percent of all people working at the Airport — those who hold a “Restricted Area Identification Card,” which gives them airside access.

The Customer Care Card contains key pieces of information reminding employees what to do if a passenger asks for assistance, including how and where to access the Language Line (a phone line that provides translation services for over 170 languages), how to identify Airport customer service personnel, and how and where to access help phones. The Customer Care Card also advises that if the worker is unable to provide the traveller with assistance, the worker should escort the traveller to a Customer Information counter or a help phone. Customer Care Cards are now handed out every time a worker renews their Restricted Area Identification Card — approximately 5,000 have been issued to date, covering all frontline staff in the terminal complex.

c. International Arrivals Response Coordinator

Mr. Ehrenholz and the internal task force realized that a mobile Airport Authority employee would be beneficial to help passengers in some unique circumstances (e.g., Mr. Dziekanski, or his mother), but were aware that customer service agents could not provide this service because they were generally required to stay in place.

Consequently, the Vancouver Airport Authority has negotiated special protocols with the Canada Border Services Agency to allow a newly created International Arrivals Response Coordinator to go in and out of the Customs Hall to deal with certain types of issues, including safety, security, or customer service, or to simply assist arriving international travellers.

d. Customs Hall Rover position

The Airport Authority has also created a new Customs Hall Rover position. This employee is required to perform hourly sweeps throughout the entire Customs Hall, including the escalators, the carousel area, and the bathrooms, to look for people who need assistance, who are lost, or who are having difficulties. The Airport Authority has both a female and a male rover to check in both bathrooms. The rovers are also required to keep records of their sweeps.

The Airport has conducted an audit of its new rover position, using a lost “mystery passenger” in the Customs Hall — the mystery passenger was identified by the rover within an hour. The Airport’s rovers have dealt with at least one real-life situation involving a lost person suffering from dementia in the Customs Hall, who was located and given assistance within an hour.

e. Re-designed customer information counter

In October 2007 a BC Visitor Centre separated the area between the International Reception Lounge and the public Meeting Area. It was dedicated to providing tourist information; yet one visitor/tourism information counsellor told me that on an average day approximately half of its 100–200 daily enquiries would be for information about flights, passengers, or Airport services. The Visitor Centre had no resources to handle such enquiries, since the booth’s computers did not provide access to baggage or flight information, the booth did not have paging facilities, and personnel at the booth had no one they could call for special assistance.

As part of the overall re-design of the International Reception Lounge and the public Meeting Area, a new Tourism BC Visitor Centre has been built — one continuous counter with direct access from both the public Meeting Area and the International Reception Lounge. Customer care personnel in this area can now dispense flight information and assist customers in any way possible. It is staffed 24 hours a day, seven days a week.

f. Improved resources for customer service agents

The Airport Authority has provided all customer service agents with mobile communication devices (BlackBerries), which they can use to call for emergency assistance, call the Operations Centre, or access the Language Line. The Airport Authority has added dual-handset telephones to all Customer Information areas, which can be used with the Language Line to access interpreters for over 170 different languages, 24 hours a day.^⁹The dual handset allows one person to speak a language and the other person to hear an interpreter’s translation of what has been said, and then reply.

In addition, the Airport Authority has distributed language identification cards to customer service agents. These cards contain the following statement in the 20 most commonly used languages: “Point to your language. An interpreter will be called. The interpreter is provided at no cost to you.”^¹⁰ The Airport has also placed globes at all customer service information booths, so that passengers who speak a language not listed on the cards can identify other languages by pointing to their country of origin.

g. New customer information counters in Customs Hall

In addition to the Customer Information counter near Secondary Immigration, the Airport Authority has installed two new Customer Information counters in the Customs Hall — the one near the baggage carousels is open whenever the Customs Hall is open, and the one in the pre-Primary Inspection Line is open between 8 a.m. and 8 p.m. They are staffed by customer service agents well versed in issues important to arriving international passengers. These counters have the same resources as other customer information counters, including dual-handset telephones to contact interpreters using the Language Line, language identification cards, and globes.

h. Help phones

The Airport Authority has placed help phones along every second post inside the Customs Hall, with larger and brighter pictogram signage. Help phones can be used to access Airport Operations, call the police for a non-emergency event, or call 911 for an emergency. If the passenger calls Airport Operations, they can access assistance or be connected to the Language Line for interpretation services. If a passenger does not dial, perhaps because they do not understand how the help phone works, that passenger will automatically be connected to Airport Operations within three seconds.

i. New “Paddle Initiative”

There is a “Voluntary Compliance Corridor” located in the Customs Hall, which allows new immigrants to bypass the Primary Inspection Line and go directly to Secondary Immigration. The “Paddle Initiative” involves a paddle-shaped sign located in the pre-Primary Inspection Line area that reads “New Immigrants, New Students, New Workers” in English and two other languages, with a large arrow directing travellers toward the Voluntary Compliance Corridor. Customer service agents in the area are trained to notice if a passenger is carrying immigration documents and to ask questions to determine if a passenger is a new immigrant and, if so, to direct the individual to the Voluntary Compliance Corridor. The Airport Authority’s audit of the Paddle Initiative showed that a large number of people appear to be using the system. This saves new immigrants time and allows them to leave the Customs Hall sooner.

j. Improved wayfinding measures

The Airport Authority has improved signage in the Customs Hall, adding LCD screens to assist travellers in finding their own way to the public Meeting Area. These screens cycle through French and English, and the four other most commonly used languages at the Airport — Spanish, Korean, Mandarin, and Punjabi.

Mr. Ehrenholz told me about other subtle wayfinding measures, such as adding a pattern of lights, and designs to the carpet, to guide passengers to find their way out, and improved tear-off maps of the Customs Hall and the Airport, which customer service agents can give to travellers to show them where to go.

Conclusions

I am impressed with the Airport Authority’s prompt and thorough review of its customer care services that it undertook following Mr. Dziekanski’s death, and the extensive changes that it has implemented. I am satisfied that if these services had been in place in October 2007, Mr. Dziekanski would not have gone missing for five-and-a-quarter hours, would have had prompt access to an interpreter and, in all likelihood, would have been reunited with his mother. I have no other changes to recommend.

5. Communication between arriving passengers and greeters

Earlier in this part, I discussed the Customs Act and the Privacy Act. According to CBSA, these statutes preclude disclosure of information about arriving international passengers to greeters. Mr. Dziekanski’s mother was repeatedly frustrated in trying to get information about him or in trying to get a message to him. I will now examine the same issue from the perspective of the Vancouver Airport Authority and review what steps it has taken since October 2007 to improve communication between passengers and greeters.

a. Telephone communication between passengers and greeters

It has always been possible for a greeter in the public Meeting Area and a passenger in the Customs Hall to communicate with each other, either by pay phone or cell phone. The Airport Authority has made several recent changes to assist passengers and greeters who do not have cell phones:

The Airport Authority’s customer service agents will now provide coins to allow arriving international passengers to place a call from a pay phone in the Customs Hall.
Customer service agents are trained to allow passengers to use the agents’ BlackBerries, to place outgoing calls.
A customer service agent who is dealing with a greeter in the public Meeting Area could phone through to a customer service agent in the Customs Hall who is dealing with the passenger that the greeter is waiting for.

b. Greeter information board

Mr. Ehrenholz told me that the Airport Authority worked closely with CBSA to implement the new “Greeter Information Board” system. Arriving international passengers may ask an Airport customer service agent in the Customs Hall to put his or her name, departure point, and time of arrival onto an electronic board that is displayed in the public Meeting Area. This allows greeters to see that the passenger has arrived and is present in the Customs Hall. The passenger’s information remains on the Greeter Information Board for two hours. According to Mr. Ehrenholz, the principal users of this system are passengers in the Secondary Immigration area. CBSA allows Airport customer service agents to enter this area and ask the people waiting if they would like to have their name placed on the Greeter Information Board. The Greeter Information Board is a notable improvement (for passengers who know about it), but it is a “one way” service — there is no comparable board in the Customs Hall on which greeters can post a message.

c. CBSA storefront counter

The Airport Authority has worked with CBSA to create a “storefront” location in the public Meeting Area. This allows an awaiting greeter to speak to a Border Services officer and to make enquiries, when a customer service agent cannot provide information regarding a passenger in the Customs Hall. While I commend the Airport Authority and CBSA for taking this initiative, it may have limited usefulness as long as officers are prohibited from releasing information about travellers without the travellers’ consent.

d. Paging

CBSA officers can page arriving international passengers in the Customs Hall and in the public Meeting Area, and customer service agents working in the Customs Hall for the Airport Authority and for the airlines can page passengers within the Customs Hall. However, the Airport Authority’s customer service agents are not permitted to page from the public Meeting Area into the Customs Hall, or vice versa. While Mr. Ehrenholz told me that CBSA is concerned that such paging would violate border security laws, the CBSA’s senior policy advisor told me that he did not know of any security concerns relating to paging.

e. Passenger record of entry and exit

According to Mr. Ehrenholz, the Airport Authority has been unsuccessful in obtaining CBSA’s agreement to implement a new “Passenger Record of Entry and Exit” system. This system would collect and time-stamp passengers’ passport data at the Primary Inspection Line, and then track passengers as they progress through the Customs Hall, including passengers who are referred to Secondary Customs and/or Secondary Immigration. When greeters provide detailed information regarding the passenger (e.g., birth date), Airport Authority staff at Customer Information counters would query a passenger’s status in the Customs Hall, and pass this information on to the greeter.

According to Mr. Ehrenholz, the Airport Authority is not allowed to implement the system because it involves “customs information,” which only Border Services officers are permitted to handle. He testified that the Airport Authority supports CBSA implementing the system because it would provide a method to track a passenger who spends a prolonged period of time in the Customs Hall. He indicated that CBSA is looking at this system.

Conclusions and recommendations

I acknowledge the efforts made by the Vancouver Airport Authority and CBSA, separately and collectively, to improve communication between arriving international passengers and greeters. However, more can and should be done.

I unreservedly endorse the Airport Authority’s attempt to introduce a Passenger Record of Entry and Exit system. It is probably the single most significant reform that CBSA could introduce to monitor arriving international passengers, track their progress through the Customs Hall, and alert CBSA officers when there are unexplained delays in a passenger’s progress.

Earlier in this part, I recommended that the Attorney General urge the federal Minister of Public Safety to implement a single integrated database system for precisely this purpose. I remain hopeful that this recommendation will be acted on.

With respect to communication between arriving international passengers and greeters, I do not understand CBSA’s lack of action on several issues:

mounting a Passenger Information Board in the Customs Hall, on which waiting greeters could place their name, so that arriving passengers were aware of their presence; and
not allowing the Airport Authority’s customer service agents to page from the public Meeting Area into the Customs Hall, and vice versa.

In neither case is CBSA being asked to disclose confidential passenger information, nor am I aware of any other security concerns. If greeters and passengers can communicate directly with each other via cell phones, there seems to be no reason why these types of services cannot be provided so passengers and greeters can communicate indirectly.

Recommendation 4

I recommend that the Attorney General urge the federal Minister of Public Safety:

To install, in the Vancouver International Airport’s Customs Hall, a digital Passenger Information Board on which waiting greeters can place their name, so that arriving passengers are aware of their presence.
To permit the Vancouver Airport Authority’s customer service agents to page from the public Meeting Area into the Customs Hall, and vice versa.

6. Safety and security

The Vancouver Airport Authority contracts with Securiguard for safety and security services at the Airport. At any given time, 20–30 Securiguard personnel act as:

security patrollers, moving throughout the Airport to respond to disturbances or medical distress calls; or
access control point guards, stationed at certain doors to protect the Primary Security Line that separates public areas of the Airport from secure areas.

Security patrollers are prohibited by provincial law from carrying any kind of weapon, defensive tool, or restraining device. They are bound by an “observe and report” policy, which specifically prohibits them from engaging in physical force, even in cases of property damage or violence, except when they need to protect themselves. In violent situations, security patrollers are taught to report back to the Security Operations Centre or to the security shift manager. The RCMP will be called in cases involving violence to people or property, incidents of theft and vagrancy, or suspicious circumstances.

During the Dziekanski incident, three security patrollers, who were together on a tea break in the Domestic Terminal, attended the International Reception Lounge. It took them approximately seven minutes to reach the lounge. One of the security patrollers asked questions of several witnesses and persuaded Mr. Dziekanski to put down a computer and to calm down. They realized that Mr. Dziekanski did not speak English, but did not alert the Security Operations Centre of that fact and took no steps to obtain interpreter assistance. Otherwise, they adhered to their “observe and report” mandate until the RCMP officers arrived several minutes later.

I was interested to learn of four changes that the Airport Authority has made to its safety and security services since October 2007:

It has installed two additional closed-circuit cameras to view the International Reception Lounge;
It has extended training about the Language Line to all security personnel;
It has provided training in de-escalation techniques to all 80 frontline Operations personnel; and
It has created a new Public Safety Officer position. These Securiguard officers are trained in verbal de-escalation techniques. One of these public safety officers is on duty at all times.

Conclusions and recommendations

Vancouverites are justifiably proud of their international Airport. The Airport Authority’s thousands of direct employees and employees of contractors serve tens of thousands of travellers who arrive and depart daily, as well as the many thousands of friends and family members who meet or bid farewell to travellers.

With such a busy enterprise, it is inevitable that there will be medical and behavioural crises, and often it will be the security patrollers employed by Securiguard who are the first responders. It surprised me to learn that these patrollers have no mandate to intervene in emergency situations. My understanding is that they are not expected to provide first aid or to use verbal de-escalation techniques, and are bound only to “observe and report.” Such a mandate may be appropriate for security patrollers in a small suburban mall, but in my view more should be expected of first responder security patrollers at such a large, busy, and prestigious international Airport.

I am not suggesting that the security patrollers carry weapons or restraining devices or physically intervene in violent situations, but I do think that the current “observe and report” mandate is inadequate. The travelling public would be much better served if security patrollers received training in first aid and verbal de-escalation techniques, and were expected to actively assist members of the public who are in distress.

Recommendation 5

I recommend that the Vancouver Airport Authority:

Revoke the current “observe and report” mandate applicable to its contracted security patrollers.
Set minimum standards for security patrollers that include:

training in first aid (including CPR) and verbal de-escalation techniques; and
an expectation that they will actively assist members of the public who are in distress.

7. Emergency and medical response

In addition to its Operations personnel and the contracted-out safety and security services described above, the Vancouver Airport Authority has its own in-house capacity to respond to aircraft and medical emergencies. Emergency Response Services operates on a 24-hour, seven-day-a-week basis. Its members are trained to firefighter standards, although their training focuses on air crash rescue, not structural fires. They are also trained to be first responders to medical emergencies.

In other respects, the Airport Authority relies on external emergency services, such as the RCMP and Richmond Fire-Rescue (accessed via E-Comm dispatch services), and the BC Ambulance Service.

In October 2007, the BC Ambulance Service stationed bicycle-equipped paramedics on site in the Airport terminal between 6:30 a.m. and 5:30 p.m. Outside these hours, the BC Ambulance Service was dispatched from Richmond, and the Airport’s Emergency Response Services personnel responded to Code 3 medical emergencies.

Earlier in this report, I summarized what happened during the Dziekanski incident — Cst. Bentley requested that his call for an ambulance be upgraded to Code 3 and the BC Ambulance Service dispatched basic and advanced life support units, but the Airport Authority’s airport response coordinator directed that Emergency Response Services not be dispatched, and one of the Airport’s automated external defibrillators was not brought to the scene. An RCMP officer refused the firefighters’ request to remove the handcuffs, but subsequently complied with a paramedic’s request.

I was interested to learn what changes have been implemented since the Dziekanski incident, particularly to deal with cases where a police use-of-force incident evolves into a medical emergency. Mr. Ehrenholz testified about the changes, which I summarize as follows:

During the period when the BC Ambulance Service’s “bike squad” is not onsite (between 5:30 p.m. and 6:30 a.m.), the Airport Authority’s Emergency Response Services now responds to all medical calls (i.e., routine and Code 3).
Two Emergency Response Services personnel are stationed in the terminal, rather than in ERS’s fire hall adjacent to the runways, to facilitate faster response times.
All 38 Emergency Response Services personnel, previously trained to a First Responder Level 3, are now trained to an Emergency Medical Responder-1, which includes the authority to administer some drugs.

Conclusions and recommendations

I commend the Airport Authority for implementing these changes. Enhancing the medical training of Emergency Response Services personnel is a welcome improvement. So, too, are the decisions to station them in the terminal and to mandate that they respond to all medical calls when the BC Ambulance paramedics are not on site. In many instances this is bound to shorten the response time, when a minute or two can make a huge difference.

However, there is one other medical emergency issue that warrants the Airport Authority’s attention. The Dziekanski case is an example of a safety and security incident evolving into a police use-of-force incident and then evolving further into a medical emergency incident. The testimony from our evidentiary hearings reveals confusion about who is responsible for what in such situations. There is no question that when the four RCMP officers arrived on the scene they took charge of the incident, and in those circumstances, it was entirely appropriate for the Airport Authority’s Operations personnel to defer to them. However, the police use-of-force incident very quickly shifted into a medical emergency incident. In such circumstances, it is not clear whether Operations personnel have an ongoing obligation under Airport Authority policy to monitor the incident and ensure a timely response and, if so, what specific role they should play. Should the RCMP retain operational authority until the medical emergency is resolved, or should Operations personnel play some role, and if so, what role?^¹¹ In what circumstances, if any, should an RCMP officer comply with a medically based request to remove handcuffs?

In my view, the travelling public would be well-served if the Vancouver Airport Authority, the RCMP, Richmond Fire-Rescue, and the BC Ambulance Service worked together in formulating a plan of action for dealing with police use-of-force incidents that evolve into medical emergencies, the goal being to ensure that the subject receives appropriate medical care and/or treatment as promptly as possible, compatible with public safety.

Recommendation 6

I recommend that the Vancouver Airport Authority, RCMP, Richmond Fire-Rescue, and BC Ambulance Service:

Work together in formulating a plan of action for dealing with police use-of-force incidents at the Vancouver International Airport that evolve into medical emergencies.
Train, with regular updates, their personnel on any such plan of action formulated by them, including live training exercises.

D. CONCLUDING COMMENTS

The Vancouver Airport Authority has taken exceptional steps in the aftermath of
Mr. Dziekanski’s death to identify inadequacies in its policies, practices, and procedures, and to remedy them. I commend the Authority and its employees for their prompt, thoughtful, and comprehensive response.

Regrettably, I cannot be as complimentary of the response of the Canada Border Services Agency. I am not aware of any comparable comprehensive review following Mr. Dziekanski’s death, and any changes to its policies, practices, and procedures are minor and few. For example, I would have expected CBSA to have moved promptly to implement changes to ensure that no future arriving international passenger gets “lost” in its Customs Hall for five-and-a-quarter hours. Based on the evidence led at our evidentiary hearings, CBSA has taken no steps to do so, leaving it up to the Vancouver Airport Authority’s new Customs Hall rovers to make hourly sweeps of the CBSA’s Customs Hall to look for people who need assistance, who are lost, or who are having difficulties. In addition, CBSA appears to oppose several other reforms, apparently for reasons not grounded in security or traveller confidentiality:

installation of a Passenger Information Board in the Customs Hall area, so that an arriving passenger can learn of a greeter waiting for them in the public Meeting Area;
paging from the public Meeting Area into the Customs Hall, and vice versa; and
electronically recording each arriving international passenger’s arrival at the Primary Inspection Line and tracking their progress through the Customs Hall, and issuing alerts when a passenger’s progress is too slow.

I am satisfied that the changes already implemented by the Vancouver Airport Authority, if supplemented by the recommendations I have made above, will dramatically improve the experience of arriving international passengers, especially those such as Mr. Dziekanski who speak neither of Canada’s official languages, are inexperienced travellers, and are, for any number of reasons, fatigued, confused, or distraught. For example:

Customer service agents in the pre-Primary Inspection Line area can now offer greater assistance to foreign-language-speaking travellers, by connecting them to an interpreter through the Language Line;
Such agents can also steer immigrants through the Voluntary Compliance Corridor, thereby enabling them to go directly to Secondary Immigration and avoid the Primary Inspection Line;
Foreign-language-speaking travellers at the Primary Inspection Line would be told, in a manner that they understand, where else they have to go and how to get there;
Customer service agents in the Secondary Immigration area can suggest to travellers that they place their name on the Greeter Information Board so that waiting greeters will know of their arrival in Vancouver. The agents can also give travellers coins for a telephone or let them use their BlackBerry to make a local call, and can access an interpreter through the Language Line;
The Airport Authority’s Customs Hall rovers move throughout the Customs Hall area, looking for people who need assistance, who are lost, or who are having difficulties;
Implementation of my proposed integrated database system would track the progress of each arriving international passenger as they move through the Customs Hall and issue an alert when a passenger does not reach the next location within a predetermined time, prompting a search for the passenger;
A waiting greeter can get assistance from the CBSA’s storefront counter and can obtain assistance from the Airport Authority’s International Arrivals response coordinator. If my recommendations are adopted, the greeter could have the passenger paged or could post their name on a Passenger Information Board in the Customs Hall, so that the passenger knows that a greeter awaits them;
Border Services officers at Secondary Immigration would ensure that new immigrants know what is being asked of them, are able to communicate with the officer, and are assisted in their own language;
A sponsor of an arriving immigrant would be entitled to be informed whether the immigrant has arrived in Vancouver and, if so, to leave a message for them;
An arriving international passenger who has exited the Customs Hall has 24-hour access to a customer service agent at the Tourism BC Visitor Centre in the public Meeting Area, for assistance; and
An arriving passenger who is in distress in the International Reception Lounge or public Meeting Area would be assisted by security patrollers, who could access an interpreter through the Language Line, and who could provide first aid and/or use verbal de-escalation techniques to assist a distraught traveller.

Notwithstanding the Vancouver Airport Authority’s impressive response to
Mr. Dziekanski’s untimely death, more still needs to be done, both by the federal authorities and the Airport Authority, and the Canadian public needs some assurance that these additional reforms will be implemented, or if not, why not.

When the provincial Minister of Public Safety and Solicitor General announced the establishment of this Commission of Inquiry in November 2007, he committed the provincial government to action:

This incident has British Columbians, Canadians and people all over the world seeking answers with regard to not only this human tragedy, but also how the province welcomes the world to our airport. By calling a full public inquiry, we want everyone to know that all the facts will be put on the table, we will take action based on those facts and we will learn from this tragedy.

I am confident that the provincial government will keep this promise.

Recommendation 7

I recommend that, within two years of this report being made public, the provincial Minister of Public Safety and Solicitor General report publicly and in writing to the Legislative Assembly on the extent to which the federal government and the Vancouver Airport Authority have implemented the recommendations contained in this report, and if one or more recommendations have not been implemented, the reasons why.

Thomas R. Braidwood, QC, Commissions of Inquiry

A. INTRODUCTION

B. CANADA BORDER SERVICES AGENCY (CBSA)

1. Introduction

2. Policy witnesses

3. Processing passengers

a. Integrated Primary Inspection Line Database

b. Field Operations Support System

Conclusions and recommendations

4. Security in the Customs Hall

a. “Rovers”

b. Surveillance cameras

c. Instruction to be more vigilant

Conclusions

5. Communication between arriving passengers and greeters awaiting them

Conclusions and recommendations

6. Interpretation services

a. Introduction

b. The national picture

c. The situation at the Vancouver International Airport

d. Recent changes

Conclusions and recommendations

C. VANCOUVER AIRPORT AUTHORITY

1. Introduction

2. Policy witness

3. The Airport Authority’s internal review following Mr. Dziekanski’s death

4. Customer care for passengers and greeters

a. New training program

b. Customer care cards

c. International Arrivals Response Coordinator

d. Customs Hall Rover position

e. Re-designed customer information counter

f. Improved resources for customer service agents

g. New customer information counters in Customs Hall

h. Help phones

i. New “Paddle Initiative”

j. Improved wayfinding measures

Conclusions

5. Communication between arriving passengers and greeters

a. Telephone communication between passengers and greeters

b. Greeter information board

c. CBSA storefront counter

d. Paging

e. Passenger record of entry and exit

Conclusions and recommendations

6. Safety and security

Conclusions and recommendations

7. Emergency and medical response

Conclusions and recommendations

D. CONCLUDING COMMENTS