Report to the Minister of Justice and Attorney General Public Fatality Inquiry

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1 CANADA Province of Alberta Report to the Minister of Justice and Attorney General Public Fatality Inquiry Fatality Inquiries Act WHEREAS a Public Inquiry was held at the Courthouse in the City of Wetaskiwin, in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 22 nd day of February, 2012 year before Hon. B. Rosborough, a Provincial Court Judge, into the death of James Lundblad (Name in Full) (Age) of Camrose, Alberta and the following findings were made: (Residence) Date and Time of Death: Place: May 5 th, 2009; 9:53 a.m. Highway 2A south of Millet, Alberta Medical Cause of Death: ( cause of death means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization The Fatality Inquiries Act, Section 1(d)). Multiple blunt injuries. Manner of Death: ( manner of death means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable The Fatality Inquiries Act, Section 1(h)). Accidental.

2 Report Page 2 of 5 Circumstances under which Death occurred: On the morning of May 5 th, 2009 Alberta RCMP and Sheriffs were jointly engaged in the investigation of traffic violations near the Town of Millet, Alberta. The area of the investigation included Highway 2A, a primary highway proceeding north and southbound through Millet. The speed limit for traffic on Highway 2A was 100 kph. The road surface that day was paved, dry and flat. The temperature was 13 C, with bright sun, blue sky and high white clouds. Visibility on Highway 2A in all material locations was unrestricted. At approximately 9:45 a.m. police observed a motor vehicle being operated through Millet and then southbound on Highway 2A. The vehicle was believed to be speeding. Those observing that vehicle contacted police officers south of Millet in order to have them intercept this vehicle. Cst. Lundblad was one of those police officers. Cst. Lundblad was travelling northbound on Highway 2A when he was notified of the vehicle believed to have been speeding. He agreed to intercept the vehicle and, whilst in communication with others, saw the vehicle pass his location in the opposite direction. He elected to undertake a U-turn on Highway 2A in order to reverse the direction of his police vehicle and initiate pursuit. Cst. Lundblad s police vehicle was driven to the right hand side of the highway where it slowed down and activated the left turn signal. Emergency equipment on the police vehicle was not activated. Cst. Lundblad then drove the police vehicle across the lane designed to accommodate northbound traffic as he began his U-turn. Cst. Lundblad s police vehicle had been followed northbound on Highway 2A for some time prior to the U-turn by a large truck operated by Michael Debbink. Both the truck and police vehicle were travelling at a speed close to the speed limit. Mr. Debbink observed the police vehicle slow down and pull to the right hand side of the highway. He, in turn, slowed and drove his truck to the left to pass the police vehicle. When he was a short distance away, Mr. Debbink saw the left signal light of the police vehicle activate after which the police vehicle immediately turned across the northbound lane of traffic. Mr. Debbink applied the brakes on his truck and steered to the left to avoid a collision. His speed and distance prevented him from doing so and his truck collided with the police vehicle, striking it broadside. The speed of his truck at the point of impact was no less than 56 kph. Recommendations for the prevention of similar deaths: The tragic events of May 5 th, 2009 arose during the course of a routine traffic investigation. The manner in which that investigation was undertaken was itself the subject of an intensive examination by police agencies. It nevertheless remains unclear why Cst. Lundblad elected to commence his U-turn when a large truck which had been following his police vehicle for some distance was only a short distance away. Mr. Debbink s truck was clearly visible from the police vehicle s mirrors and would have been observable when conducting the standard shoulder check. When the police vehicle pulled out from the shoulder across the traffic lane for northbound traffic, a collision was unavoidable and the consequences fatal. Alberta s statutory and regulatory framework specifically addresses the driving maneuver referred to as a U-turn. The Use of Highway and Rules of the Road Regulation, A.R.304/2002, s.29(1) provides that: 29(1) A person driving a vehicle shall not turn the vehicle so as to proceed in the opposite direction unless that movement can be made in safety and without interfering with other traffic.

3 Report Page 3 of 5 This regulation governed Cst. Lundblad when making his U-turn in order to pursue a vehicle believed to have been speeding. It is obvious, of course, that the U-turn performed in this case could not be made in safety, bringing about the tragic consequences which ensued. During the course of this inquiry, I have had the benefit of hearing the testimony of James Murray Johnston, an RCMP officer with extensive training and experience relating to traffic and traffic safety matters. He is a qualified accident reconstructionist who ran the National Collision Reconstruction Program from Ottawa for several years. As of September, 2008 he has acted as K Division s Traffic Services Coordinator. Acting in that capacity, it is Mr. Johnston s responsibility to oversee and maintain traffic services policy, including the operation of police motor vehicles as well as the delivery of traffic services such as speed enforcement delivery, breath testing and impaired driving service delivery. All of the functions contained within those programs, including instrumentation, training or service delivery protocols all fall within his area of responsibility. He is required to ensure that the RCMP has effective and efficient traffic service delivery and policy infrastructure. The maneuver undertaken by Cst. Lundblad on May 5 th, 2009: a U-turn, is a common, almost routine driving maneuver for police officers. Mr. Johnston estimated in his evidence that the number of U-turns performed annually by police officers in Alberta likely numbers in the millions. Statistically, very few injury collisions ever result from undertaking this maneuver. Nevertheless, since 2003 there have been 4 fatal or serious injury motor vehicle collisions where police officers have undertaken U-turns. Those incidents prompted the RCMP to undertake a review of those incidents with a view towards preventing any recurrence. The review commenced in 2010 and ran for approximately 4 to 6 months. It concluded that, in the case of each serious injury accident, there were clear failures of perception and judgment when U-turns were performed. Oncoming traffic, like the Debbink truck, was available for view but there was a failure in detection, identification and risk assessment of that hazard. The RCMP have recognized the complex environment within which police officers involved in traffic enforcement now operate. The days of a simple radar device and radio have been replaced by a variety of technological advances which enhance the quality and effectiveness of traffic enforcement but also increase the complexity of the police officer s environment and the potential for distraction failure to perceive risk. To compensate for that, extensive changes have been made to the education, training and evaluation of police officers in the traffic enforcement environment. I am satisfied by the evidence that I have heard that the RCMP has thoroughly addressed the need for and appreciates the value of educating and evaluating police officers while engaged in this important police function. Some police activities, including activities in the traffic enforcement area, require dedicated or mandatory direction to police about steps or activities that they must or must not undertake. Police policy serves this function. An example of this is contained in RCMP Operational Manual, Chapter 5.4: Emergency Vehicle Operations (Pursuits). I stress at the outset that this policy was not intended to and does not cover the type of activity engaged in by Cst. Lundblad on May 5 th, Not all police activities and not all hazardous police activities can be directed by policy, however. Attempt to do so would be counter-productive. After hearing the evidence of Mr. Johnston, I am satisfied that to attempt creation of a policy to govern all U-turns by police vehicles would be counterproductive. I make no recommendation in that regard. Given the serious consequences in this and other cases involving U-turns, however, it would be helpful to supplement RCMP training by attempting to interpose a significant cognitive break for

4 Report Page 4 of 5 police officers between those acts preparatory to a U-turn and actually initiating that manouver. At the present time, the reversal of the signal is designed to induce a police officer to shoulder check before moving across a lane of traffic. There is no requirement that the police officer stop the vehicle and rely upon that as a more significant prompting to shoulder check for traffic. A full stopping of the police vehicle would, in my opinion, constitute a much more significant break in the chain of activity involved in a U-turn and might promote the type of check (or risk assessment ) that would avoid the type of collision that occurred in this case. This recommendation is supported by the evidence of Mr. Johnston. He stated in that regard: So we don t have a distinct break between the investigative process and the driving process, and that break could come to bring your mind back to that driving task. If -- in driver training they talk about the reversal of the signal as a teaching point, and that should trigger the shoulder check and -- risk assessment; but there is nothing about stopping the car. You are just turning a signal. If we physically stop the car -- and I can t see that we would add more than a second or so onto any given turn -- we physically stop the car and then engage as we teach them how to re-engage to a traffic lane to make the distance evaluations, the risk assessment, there is a difference between just kind of rolling through and stopping; a little difficult for us to enforce, but we could at least teach it, and our next generation of policemen would be taught that every reversal of direction starts with -- starts from a stop. If we come to a full stop, the probability is the traffic lane -- you know, we would then engage the next step which is looking to see when I can reenter the traffic. That may be a better cognitive manner of forcing the shift from investigative to driving behaviours than turning on the turn signal. While a modest recommendation at the end of the day, I nevertheless recommend that: RCMP TRAINING AND RISK ASSESSMENT RELATING TO THE CONDUCT OF U-TURNS BY POLICE VEHICLES SHOULD BE AMENDED TO REQUIRE THAT A POLICE VEHICLE BE BROUGHT TO A FULL STOP BEFORE RE-ENTERING A TRAFFIC LANE IN ORDER TO PERFORM A U-TURN.

5 Report Page 5 of 5 DATED May 31, 2012, at Wetaskiwin, Alberta. Original signed by Hon. B. Rosborough A Judge of the Provincial Court of Alberta

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