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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

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o training in first aid (including CPR) and verbal de-escalation techniques; and to me that the AED was only of use — was used on certain intention, ever, ever, to mislead the public. I'm not a liar. I don't intend to lie to anybody ever, and absolutely I'm sorry that this has gotten to the poi
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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

Description:
o training in first aid (including CPR) and verbal de-escalation techniques; and to me that the AED was only of use — was used on certain intention, ever, ever, to mislead the public. I'm not a liar. I don't intend to lie to anybody ever, and absolutely I'm sorry that this has gotten to the poi
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