The furnace and chimney at a Porter Creek home where five people died of carbon monoxide poisoning had not been properly installed, permitted or inspected, says the Yukon fire marshal’s full report released Friday.
Despite building codes and multiple lines of “defense,” errors in the renovation and maintenance of the home’s heating system built up and caused the death of the four-member Rusk family and their boarder in January, the report says.
Forty-five-year-old Bradley Rusk, his wife, Valerie, 37, their two children, Gabriel, 13, and Rebekah, 11, and their boarder Donald McNamee, 47, all died of carbon monoxide poisoning.
Their rented Porter Creek home filled with the toxic gas after the chimney completely clogged with ice.
The fire marshal’s report says little had been done properly to ensure the heating system was safe.
There was no permit or inspection done when a new burner was installed in the home. The building code that legally makes that permit and inspection mandatory came into effect in 2004. The burner was manufactured in 2009, the fire marshal’s report says.
There was also no record for the installation of the home’s boiler, which was also new to the 1960s-era home. The boiler was manufactured in 1993, the report says.
Building codes as old as 1976 also called for the chimney to be deemed “suitable and in satisfactory condition” before any new oil-burning equipment was installed, the report points out.
The chimney at 1606 Centennial St. was not in a “suitable” or “satisfactory condition.”
The stonework was falling apart and stones and mortar were falling into the chimney, blocking the passage of flue gases.
In 2004 – before the home’s burner was made – a new building code came into effect. It requires the chimney be “sleeved down” when a new oil-burner is installed, says the fire marshal’s report.
This helps to insulate older chimneys from the colder flue gases that the newer, high-efficiency burners pump out.
The report says there is no evidence the Rusk-McNamee home’s chimney was ever re-sized.
There is a record of a permit and inspection for a chimney re-lining for 1606 Centennial St. with the City of Whitehorse, the report says.
The re-lining was to be done by True North Mechanical – a business that no longer exists in the territory.
A city inspector approved the job on Oct. 8, 1991, the report says.
“But with the exception of the approximately 24-inch piece of six-inch round single-wall duct found immediately below the chimney cap, we did not observe any indication that a metal liner had ever been installed,” the report says. “In particular, we found no metal remains or debris below the level of the chimney cap.
“The installation, as observed, does not conform to any installation standard of the CSA B-139 Installation Code for Oil Burning Equipment in force in 1991, or subsequently.”
The city’s inspections department has not yet been available to comment.
A new chimney liner would have also helped to preserve the masonry chimney.
Along with natural weather, the stonework was also exposed to years of the corrosive mix in the “combustion products.”
Those “products” or flue gases are supposed to be diluted – they weren’t in the Centennial Street home. There was no combustion air duct found for the boiler, the report says.
But there were two maintenance stickers found on the burner. One was dated Oct. 27, 2010, the other Oct. 14, 2011.
The more recent servicing didn’t include a “combustion analysis,” the report says. “No oil” had been written on the sticker.
There was no indication that the servicemen were called back to check the combustion after the oil tank was refilled.
The fuel tank was empty during the fire marshal’s investigation as well. The tank was also improperly installed, the report says.
If the furnace’s combustion were checked, it would have been found that it was set too low.
Under-firing is common because it means less fuel is needed and the appliance becomes more efficient. But it also means the “stack temperature” or the temperature of the flue gases going up through the chimney were much lower.
To under-fire a burner, a certain size nozzle must be installed. The nozzle installed in the Rusk-McNamee home was not the right size.
“It should be noted that any reduction in burner firing rates impacts appropriate chimney sizing,” the report says. “In this case, it appears that there is a direct connection between lower stack temperatures and consequent ice buildup. That is a particularly dangerous situation in the context of a chimney that is already partially blocked through collapsed masonry.”
When firefighters arrived on the scene Jan. 29, they saw flames coming out of the boiler, meaning it was still running, continuing to pump toxic gases back into the home, thanks to the blocked chimney.
Firefighters turned it off, opened windows and continued to use breathing apparatuses until the level of carbon monoxide in the home had gone down. When the fire department first entered the home, the level of carbon monoxide was so high it was out of their detector’s range, the report says.
Once the fire marshal was able to inspect the appliances and chimney, they were all found caked in soot and debris.
Initially, the fire marshal only released a summary of conclusions from his investigation. The full report was sent to the coroner, whose investigation is still ongoing.
The decision to finally release the full report came after the coroner confirmed it would not jeopardize her investigation, said Department of Community Services spokesmen Matt King. Releasing the full report will also help clear speculation of the cause of this tragedy, King said.
There is no indication when or if the coroner will call a public inquest into the deaths.
The government has mandated a working group on oil-fired appliances and tanks.
That group is being organized by the Yukon Housing Corporation.
The corporation had a similar group, while not government-mandated, after the territory received damning reports on oil-burning equipment a few years ago.
Those reports came by studies commissioned by the Yukon Housing Corporation.
Past mandating this group, the government has not done anything else in response to this tragedy – including instituting any regulations on the industry, as were aggressively called for in the past reports.
If you have any comments or suggestions to the working group, send them to OFA@gov.yk.ca before April 16.
Contact Roxanne Stasyszyn at firstname.lastname@example.org