Source: https://thegunblog.ca/2017/10/04/rcmp-failed-to-provide-guns-training-full-text-of-court-ruling/
Timestamp: 2019-04-24 02:59:58+00:00

Document:
TheGunBlog.ca — The following is the full text of a Sept. 29 court ruling that found the RCMP guilty of failing to provide AR-15 rifles and training to its officers, three of whom were shot to death in June 2014 in Moncton, New Brunswick. CBC, which provided live updates of the trial, reported last week on the judge’s decision here.
The 64-page ruling was sent to TheGunBlog.ca by the court. The bold was in the original.
 On June 4, 2014 an assailant armed with, among other weapons, an M305 semi-automatic .308 Winchester rifle and at least sixty round of ammunition murdered three general duty Royal Canadian Mounted Police (RCMP) members and wounded two others.
 In the aftermath of this tragedy the RCMP was charged with four offences pursuant to section 124 of the Canada Labour Code R.S.C.1985 c. L-2 (the “CLC”) alleging a failure to ensure the health and safety of every person employed by it by failing to provide appropriate use of force equipment, training and adequate supervision.
 Section 124 enacts what is commonly called a “general duty” to protect workers and is preventative legislation which imposes a duty on employers to “ensure that the safety and health at work of every person employed […] is protected”.
 It is noteworthy that the RCMP has not been charged that by any act or omission it caused the death of or injury to its members. That is not an issue in this trial.
 It was conceded at the opening of the trial that all members who responded to the June 4th incident in Moncton were employees of the RCMP for the purposes of s. 2 of the CLC.
 The defence of “due diligence” is available to any person charged with an offence under s. 124 of the CLC (s. 148 of the CLC) and the RCMP asserts that it exercised due care and diligence to avoid any contravention of the CLC.
 The Crown alleges that following the institution of the Immediate Action Rapid Deployment (IARD) policy in 2006-2007 which required front line general duty members to immediately respond to and stop an “active threat”, RCMP use of force experts knew that the current RCMP weaponry (service pistol and shotgun) required updating to ensure that responding members were equipped to safely and effectively respond to such incidents and advised RCMP management accordingly.
 In spite of this, some seven years later there were no carbines in Moncton on the night of June 4, 2014 and no personnel that were trained on their use by the RCMP. The Crown asserts that by this time the RCMP had known “for years” that the patrol carbine was the appropriate weapon to respond to an armed suspect such as the one members were confronted with on June 4, 2014, had in fact approved the patrol carbine for use by general duty members in 2011 and had begun an incremental rollout. The delay in equipping and training members, says the Crown, is inexcusable.
 The Crown also asserts that the RCMP failed to provide both responding members and their supervisors with appropriate training in how to respond to an active shooter event in an outdoor or open environment, thus leaving members without appropriate tactical training to enable them to respond effectively and safely to the June 4, 2014 incident.
 With respect to Count one, the Defence suggests that the Crown has failed to prove the actus reus of the offence. Because there is no specific regulation alleged to have been breached (such as for example, failure to wear protective footwear), the Crown must prove not only the act or omission alleged but also that the act or omission constituted a reasonable precaution in the circumstances. The Defence posits that while an accident or an incident may, in some circumstances, provide evidence of a breach of duty, the mere fact of the accident or incident will not necessarily satisfy the burden on the Crown to prove beyond a reasonable doubt that a prima facie breach of the duty of care occurred.
 Alternatively the Defence asserts that it has shown on a balance of probabilities that the RCMP took all reasonable steps in the circumstances to avoid the occurrence of the prohibited act. Their position is that the need for patrol carbines for general duty members did not become “fully apparent” until the results of the Firearms Capability Evaluation were presented to Community and Aboriginal Policing (CAP) in January 2011 and that the remaining time was required for the RCMP to exercise its due diligence in obtaining patrol carbines and commencing training of its members.
“failing to provide RCMP supervisory personnel with appropriate information, instruction and/or training to ensure the health and safety of RCMP members when responding to an active threat or active shooter in an open environment”.
the onus rests on the Crown to prove those allegations beyond a reasonable doubt. This they allege has not been done and thus the Crown has failed to prove the actus reus of the offences because it failed to prove that the precautions outlined in the Counts were reasonable precautions to be taken in all the circumstances of the case.
 The Crown confirmed to Defence in advance of the trial that this Count contains no additional allegations beyond those set out in the first three Counts and therefore if a conviction is entered on any of them the principles enunciated in R. v. Kienapple would apply and this count would be judicially stayed.
 The April 20, 1999 shootings at Columbine High School in Colorado changed the way general duty officers and first on scene officers responded to ongoing life-threatening incidents. Prior to this, the prevailing policy for police forces was that the first responders should secure the scene and wait for specialized units such as Emergency Response Teams (ERT) to arrive to confront the shooter. At Columbine, while the responding officers waited for the Special Weapons and Tactics Team (SWAT) to arrive, the perpetrators continued their murderous rampage for some forty minutes. (See Exhibit 66 at page 10).
 Police agencies across North America, including the RCMP, began to change their policies and procedures for responding to an “active threat”. By late 2006 or early 2007 the RCMP had developed an IARD policy for such events. This policy applied to situations “where on-duty members must stop an active threat causing death or grievous bodily harm” (Ex.1, Tab 2, 1.1). An active threat is defined as “one or more individuals who seek out an environment that offers multiple potential victims at risk of death or grievous bodily harm not easily able to escape the threat” (Ex.1, Tab 2, 2.1). Police priority during an IARD is “to stop the active threat in accordance with the principles of IMIM” (Ex.1, Tab 2, 1.9). These policies were in force on June 4, 2014; however the policies and training were all geared towards responding to such an event in an indoor or confined setting, such as a school, shopping mall or similar structure; additionally IARD training, other than that received by Cadets at Depot during initial training, was not mandatory.
 Two events which occurred between the Columbine and Moncton shootings also had an impact on the question of the duty of the RCMP to protect its members. I refer to the murder of four members in Mayerthorpe, Alberta in 2005 and the murder of two members in Spiritwood, Saskatchewan in 2006, all of them at the hands of an assailant armed with a long barreled weapon.
 In Mayerthorpe, RCMP members who were executing a search warrant were ambushed in a Quonset hut by an assailant who had surreptitiously entered the hut during the night. Following the incident, an Incident Management Review was conducted by the RCMP in 2008 and a Public Fatality Inquiry held in 2011 presided over by Assistant Chief Judge Pahl of the Provincial Court of Alberta.
“RCMP members should be appropriately armed. The evidence at this Inquiry was that the RCMP no longer offers long gun training to its recruits. This reflects the RCMP’s assessment that rifles are not widely used, present a high risk of collateral damage and require individual adjustment. As well, proficiency in their use is a highly perishable skill. As a result of these and related issues, the potential for the implementation of an Active Shooter Response Program was recommended by an RCMP report and is being examined. This recommendation is designed to improve timely access to heavier, long barreled weapons, primarily for ERT, but is also addressing the availability of patrol carbines for use by general duty members. This would increase response capabilities above the current shotgun and pistol deployment […] Senior Deputy Commissioner Knecht testified that the rollover from shotguns to patrol carbines is underway and I can only suggest that this initiative be accorded high priority. I am not qualified to comment on these changes, but I am satisfied that Commissioner Knecht is and that he believes they are in the best interest of all members. I need not say more as I am satisfied that the RCMP continues to assess and enhance its ability to meet threats which are themselves constantly evolving.” (Ex.2, Tab 14, P. 23).
“From the actions taken by members at the scene it would appear that they were applying the principles of the IMIM by continually assessing the situation as it changed or more information became available by considering the resources they had available and by developing a plan in line with these resources and the information they had.
The result of taking these steps was a rescue effort with no further injury to anyone else involved.” (Ex.2, Tab 10, Pgs 68-69).
A compliance date of October 29, 2007 was given for all items and agreed to as evidenced by the signature of Assistant Commissioner Darrell McFadyen on August 30, 2007.
The document notes that of the long guns currently available to RCMP general duty members, one is no longer manufactured (the Remington Model 70, .308 rifle adopted in 1960), and the other, the Remington Bushmaster 870, 12 gauge shotgun adopted in 1962 is the only long gun available to address active shooter situations.
 The briefing note lists as benefits of the carbine that it had been identified as an appropriate long barrel weapon system for patrol officers by firearm experts, was the industry standard, the Ontario Provincial Police (OPP) already had a semi-automatic carbine, and that previous inquests had identified the requirement for a precise long barreled weapon for law enforcement.
 The recommendation given to the Deputy Commissioner was that CAP continue to research both the feasibility of the project and efforts to identify appropriate specifications for a detachment rifle. On May 28, 2007 approval was granted and Stuart commenced work on it along with the eleven other projects for which he was responsible, including a needs analysis for Hard Body Armor (HBA) for general duty use, which was another recommendation stemming from the Mayerthorpe Public Fatality Inquiry.
 On October 14, 2007 an unarmed civilian who had arrived at Vancouver International Airport died following the use of a Conducted Energy Weapon (CEW), also known by the brand name “Taser”. The fallout from this incident was a great concern to RCMP management and so for the next two years no further work was done on the carbine project. Both Stuart and Superintendent (then Inspector) Lightfoot, who at that time made up the Use of Force section, testified that the Vancouver incident became the focus of all they did for the next two years as they revamped CEW training, made changes to IMIM and commenced a data bank for reception of statistics relating to use of force by members. D/Com Darrell Madill (Ret’d) who was the Officer in Charge of CAP from 2008 until he retired in 2011, testified that during his tenure the CEW was front and center of all they did and that he prioritized the CEW over the patrol carbine because he put the resources to, in his opinion, the area of greatest need. In any event it is clear that until 2009 nothing concrete was done to move the carbine project forward.
“Changes to policy appear to have appropriately considered the experiences of external sources, but failure to correlate this data to RCMP-specific experiences amounts to a significant oversight, which should be redressed at the earliest opportunity.
 RCMP management took this to mean that any use of force decision required a rigorous and independent analysis of both external and internal experiences. Madill says he feared that RCMP members would lose the CEW as a use of force option, although neither report suggested that. He also said that he learned from the CEW incident that it was impossible to rely on the experiences of others as justification for a change in use of force strategy. Stuart testified that his view was that the RCMP was being criticized for not having done sufficient research before purchasing CEWs. Lightfoot testified that he was told by senior management that because of the Commission report, independent and “better” research was needed to justify changes. He opined that there needed to be a focus on independent and Canadian research to satisfy what he termed ”special interest groups” who had expressed concerns following the CEW incidents. When asked who the “special interest groups” were he said they included an academic who did a paper on the Vancouver Airport incident, the media, the Commission for Public Complaints against the RCMP and The Standing House Committee on Public Safety.
 In early 2008 Lightfoot, who was at the time the OIC of the Use of Force Section “floated” the idea of having the Canadian Police Research Centre (CPRC) do some research on the carbine project, however he says he was told by senior management that they were not seen as independent enough as they had done work on the CEW policy.
 By March 2009 as the work on the CEW was nearing completion, Lightfoot began to seek out someone to do research on the carbine project and was eventually put in touch with Professor Darryl Davies, an Instructor in the Department of Sociology and Anthropology at Carleton University. It is clear from a review of his Curriculum Vitae (Ex. 12) that he is a social scientist and academic who had worked in the past for Correctional Service of Canada, the Ombudsman’s Office of the Department of National Defence, and the Department of the Solicitor General (Federal).
 Lightfoot says he gave this to Davies who said he could do the work, while Davies says that he told Lightfoot that he had no knowledge of guns, didn’t own one but would be happy to do a research project, that is, a literature review and a survey.
 In any event, Lightfoot had no further contact with Davies after this as he left the unit, returning in April 2010. Davies was eventually contracted to do a report, entitled “Aiming for Safety: A Needs Analysis to Determine the Feasibility of Adopting the Patrol Carbine in the RCMP” (Ex. 1, Tab 7), which he delivered in March 2010. It appears that during the work on the contract, Davies essentially worked alone with the exception of some work done on the questionnaire which was sent out to both RCMP members and other agencies that had patrol carbines. Davies proposed a roundtable with RCMP members to obtain their views on a patrol carbine however this was rejected by RCMP management for budgetary reasons.
“Our expectation was that you would provide as analysis of the review and survey results and how they would relate to the needs analysis regarding possible adoption of a patrol carbine for the RCMP.
It may have been beneficial to clarify those expectations, and others related to a draft or finished report, when the statement of work was prepared. We have learned from this experience and will certainly keep it in mind when developing future contracts within our directorate.” (Ex.1, Tab 9, Pgs 1-2).
“The results of your needs analysis were expected to answer the question as to the direction the RCMP should take in regards to equipping general duty members with a patrol carbine. The expectation of the reviewers was that the report would provide an evidence-based rationale for or against the implementation of a patrol carbine for the RCMP, based on the Canadian experience.
The conclusions reached were not supported by the material reviewed. […] The report does not contain appropriate consultation and detailed information required to assist us with making an informed decision regarding the advancement of the Patrol Carbine Project.” (Ex.1, Tab 8, Pgs 1-2).
[36} The above may be viewed as a fair comment and an expression of the RCMP’s view of the report, however it was the gratuitous comment contained in the last paragraph of the letter which ignited a flurry of angry e-mails and threats of lawsuits which continued until January 2011 when then Deputy Commissioner Knecht convened a meeting of the parties and defused the matter.
 By March 2010, CAP had decided that the Davies report was insufficient to meet their needs and were assessing other options to obtain a needs analysis including having made contact with CPRC, the agency they had rejected two years earlier. (Ex. 7, Tab 12). Lightfoot had several meetings with Dr. Kate Kaminska of CPRC in the spring and summer of 2010 to establish roles and responsibilities before CPRC undertook the project.
 Dr. Kaminska, who was declared an expert in scientific research and analytic methodology, including project design and implementation, holds a Bachelor of Science degree in Engineering Physics and a Ph.D. in Physics, both from Queen’s University, Kingston, Ontario, and is Adviser to Chief of Staff (Science and Technology) at Defence Research and Development Canada in Ottawa. From April 2010 until November 2015 she was part of an operational research team which worked on specific projects, one of which was the firearms capability project for the RCMP.
 Dr. Kaminska testified that in any project one must firstly decide what the project involves, what the Centre can do and in what time frame, which involves a bit of negotiation. She explained that part of that exercise is to understand what exactly the client wants, noting that often clients are “not terribly articulate” as to what they want. She put together a project charter (Ex.8, Tab 14) outlining roles and responsibilities and worked with a team which included both outside researchers and academics, Lightfoot and Stuart as well as Cpl. Kirk Chiasson from the RCMP and Dr. Simona Verga from her agency.
In fact, however, the results were known to RCMP management on January 17, 2011 (Ex. 8, Tab 15, P. 2) and the team had started working on what was known as the “solutions phase” before May 2011.
 On January 28, 2011 Lightfoot along with the Director General of CAP (now D/Commissioner) Kevin Brosseau, was summonsed to Senior Deputy Commissioner (now Chief of Police of Edmonton Police Service) Knecht’s office to discuss progress on the patrol carbine project. The Senior Deputy had been subpoenaed to testify at the Mayerthorpe Inquiry and requested Lightfoot to bring him up to speed on the project and was “taken aback” by the lack of progress on the project. In the past Knecht had been frustrated by the length of time it took to make decisions in Ottawa and says that in transferring to Ottawa he thought he might contribute to speeding up the process. He says that Lightfoot told him that he was ninety nine per cent sure of what he was going to recommend and so he told Lightfoot and Brosseau that we are going to roll out the carbine project as he wanted to ensure that the project would move ahead.
 Lightfoot says that Knecht told him to identify an “off the shelf” solution while Knecht says he doesn’t recall using those words, although he allows that it is wording he may have used. In his mind it meant that you don’t have to a carbine with all the “bells and whistles” just a basic model that meets the needs. Paraphrasing what he said at trial, “you don’t need a Cadillac nor a Volkswagen, but why not a Chevrolet”.
 Knecht testified that it was an easy decision to make but not one that could be easily done, it would take time. Top of mind was the need to liaise with the contract partners, provinces and municipalities, and get them on board. He knew there would not be carbines on the street the next day but believed eighteen months was a realistic goal to strive for. However Knecht left the RCMP in June 2011 to assume his current position with the Edmonton Police Service.
 By that time the solutions phase of the carbine project was underway. As Dr. Kaminska was on maternity leave this phase was headed by her colleague Dr. Simona Verga who was also declared an expert in scientific research and analytic methodology, including project design and implementation. Dr. Verga holds a Bachelor’s degree in Physics from the Institute of Microtechnology in Bucharest, Romania and a Ph.D. in Physics from the University of Alberta. It was she who principally authored the report entitled “Firearms Capability Evaluation-Solution Phase” (Ex.3, Tab 16) again with contributions from Stuart, Chiasson and Lightfoot from the RCMP, four other researchers from her own agency, and the RCMP Chief Armourer.
 While work on the solutions phase was ongoing, Lightfoot began the process of having the patrol carbine approved for use by the RCMP. This involved appearing before the Senior Executive Committee (SEC), the body that must approve any change of armament for the Force. He prepared a PowerPoint presentation (referred to as a “deck”) seeking approval of the Colt C8 patrol carbine which he presented to the SEC meeting of April 20, 2011 (Ex. 8, Tab 19A). SEC wanted further information which was prepared and at the September 6, 2011 SEC meeting a further deck was presented (Ex.8, Tab 20A) following which “SEC approved the addition of a patrol carbine (based on the Colt C8 platform) to the inventory of firearms available to front-line members.” (Ex.8, Tab 20B).
 Approval of the patrol carbine for front-line members having been given, it then became necessary to determine how, when and in what manner the carbines would be distributed to front line members, and to establish how the project would be funded. Inspector Larry Brookson was OIC of the Use of Force Section from December 2011 until June 2013. He was tasked by Brosseau to manage the carbine project. He set up various templates to track progress on the various parts of the project. Two Boards were established; the Carbine Project Board, made up of the OIC and other senior officers in CAP as well as representatives from other directorates (such as Learning and Development (L&D), Finance, and Uniforms and Equipment) which would be impacted by the project, and the Project Investment Board, comprised of the D/Commissioners and other top ranking officers. The first Board looked after details of the carbines (what sort of trigger, optics and storage options should be used) and the other dealt with financing issues or changes in direction of the project. Both Boards met regularly and produced briefing notes and minutes of decisions all with a view to keeping the carbine project on tract and eventually securing senior management approval. When Brookson left in June 2013 the carbine use policy had been completed, training prepared by L&D and the first batch of the 375 carbines approved had been delivered.
“an incremental implementation of a divisional deployment strategy. Divisions through the “Risk/Threat Deployment Assessment Matrix” identify the locations requiring firearms and complete divisional user training in Divisions” (Ex. 8, Tab 22A, P.9).
 A draft of a “Detachment Threat/Risk Assessment Tool for Patrol Carbine Deployment” was prepared and sent out in December 2011 to the Divisions (that is the Provinces and Territories in which the RCMP provides policing services on a contractual basis) asking each Division to have the document completed by a named Detachment. In the case of J Division (New Brunswick) it was the Blackville Detachment. The document asked for information on subjects such as Member Involved Shootings (MIS), presence of firearms in the area, Subject Behaviour Officer Response Reporting (SBOR) statistics, size and access ability of detachment, ERT response times, patrol carbine availability in other police services, public support of carbines and whether or not there was “financial support” for the purchase of carbines. The last issue was a contentious one as the initial draft of the document contained no questions as to cost; however senior management insisted that it be part of the tool.
 The final version of Risk Assessment Matrix was sent by C/Supt. Brenda Butterworth-Carr, then Acting Director General, National Criminal Operations of CAP, in March 2012 to all Divisions requesting that they have each detachment or unit complete the questionnaire. The completed questionnaires were then to be returned to the district who, using the provided scoring template, would apply the scoring values to the questionnaires.
The revised questionnaire in addition to the information requested in the first draft, also gave details on the estimated costs of the weapon, ammunition, training and maintenance. The Preamble quoted at paragraph 47 does not appear in the final document.
 On May 17, 2012, J Division provided its completed carbine evaluation chart and a week later, presumably on the basis of that evaluation, placed an initial order of twenty-two carbines and necessary ancillary items as well as twelve more in each of the following four years. By July 4, 2012 Butterworth-Carr is again corresponding with the Divisions asking that they confirm that they have the funding for the purchase of the carbines they have ordered and J Division replies in the affirmative on July 11, 2012.
 Commissioner Paulsen granted approval for the initial rollout of 377 carbines on July 17, 2012, amended later that month to add an additional 125 carbines for E Division. (Ex. 9, Tab 47).
 Although approved, carbines did not immediately start to be rolled out. The following fall and early winter were consumed with contracting with Colt Canada and other suppliers for the carbine and ancillaries and developing the necessary training programs. Indeed it was not until March 21, 2013 that the first completed order for 527 carbines were received by the RCMP Armourer for fitting and final approval. In the same month the Carbine Operator Trainer Course pilot was held at Depot in Regina, Saskatchewan.
 Carbines began to be shipped out to divisions in August 2013 with all being shipped out by the end of the week of September 9, 2013. J Division received their order of 22 carbines on September 12, 2013 and commenced contact with CFB Gagetown, the only available firing range, as to available dates for a carbine operator course. The plan was to have fifty percent of officers trained within five years. Eventually the first courses were set for May 9 and June 6, 2014 (Train the Trainer) and June 2-6, 2014 for a carbine operator course. (Ex. 8, Tab 28).
 So it was that on June 4, 2014 there were twenty two patrol carbines available for RCMP general duty members in New Brunswick and all of them were at CFB Gagetown being used for training purposes. As of that date Hard Body Armor (HBA) had recently arrived at Codiac Detachment with members being advised of that fact by way of e-mail and being directed to familiarize themselves with the equipment.
 The CLC is clearly preventative legislation imposing a standard of care on employers to take all steps reasonably required to ensure employee health and safety against risks they may face in the course of their employment.
 Section 124 enacts what is known as a general duty clause. There is no allegation of breach of a specific regulation made under the CLC; however it is not incumbent on the Crown to establish that fact in order to sustain a conviction. R. v. Saskatchewan Wheat Pool 2000 SKCA 73 at paragraphs 12-14.
 The determination of whether or not an accident or an incident provides evidence of a breach of a regulatory offence is one that can only be made following a consideration of all relevant circumstances and identification of the specific elements of the offence charged. This was the conclusion arrived at in R. v. St. John’s (City), 2016 CanLII 28455 at paragraph 36.
 Due diligence however does not require superhuman effort. A defendant must take all reasonable steps to avoid harm, but this is not the same as all conceivable steps, only those steps that could be reasonably expected in the circumstances. R. v. Maple Lodge Farms, 2013 ONCJ 535 (CanLII) at paragraphs 363-364.
 The Crown has chosen to particularize this Count by alleging a failure to provide appropriate use of force equipment, which would include the patrol carbine and (HBA), as well as appropriate training in their use and therefore must prove beyond a reasonable doubt that the provision of these items would constitute a reasonable precaution to be taken. As noted above there are no specific requirements in the CLC which would require the RCMP to provide either patrol carbines or HBA to its members.
 With respect to patrol carbines the first question may be when did the need for a patrol carbine become obvious? It is clear that as early as 2007 RCMP management was aware of the limitations in the existing armaments, the pistol and shotgun. Both Stuart and Lightfoot testified that instinctively they knew that front-line members were outgunned when facing heavily armed adversaries but in their view they needed research to justify their position.
 It is also clear that following Stuart’s Briefing Note to the Deputy Commissioner in March 2007 and the approval to start research on the issue all work on the carbine project was curtailed after the CEW incident in Vancouver for a period of two years. The delay was occasioned not only by the enormous amount of work done by Stuart and Lightfoot on CEW policies but also the lack of sufficient personnel at Use of Force section.
 It is clear to me that RCMP management were “smarting” after the criticism levelled at them following the decision regarding CEW use, particularly that coming from those groups providing some level of civilian oversight on their activities, and were determined not to be in that position again. This mindset manifested itself in the almost hypervigilant need for research before taking any action.
 Another delay was occasioned by the rejection of the Davies Report and the engagement of Defence Research and Development Canada (DRDC)-Centre for Security Science, formerly CPRC, to do a needs analysis. While it could be acknowledged that the Davies Report was inadequate for RCMP purposes this speaks more to the inadequacy of the process of hiring Davies than either his abilities or the quality of his work. While Lightfoot in his testimony would not admit that it would be impossible for a single social scientist to prepare a report containing all the information requested in the Statement of Work (Ex. 1, Tab 6), saying only “He said he could do the work”; given that it took DRDC with a team of experts (including two who had Doctoral degrees in Physics), some eighteen months to prepare their analysis it would be clear to any reasonable and well informed observer that Davies could never have fulfilled that mandate.
 When D/Com Madill came to CAP in 2008 he created an “issues tracking matrix” in order to understand the issue which the Directorate was facing and track progress on those issues. Ex 7, Tab 9 is an example of this document. There are some twenty-one items on the matrix ranging from the CEW, HBA, a new IMIM model and patrol carbines to Detachment Clerk Review and Senior Leadership Selection Process Review, so obviously some prioritizing of issues would be necessary. A live issue in this analysis is whether or not the patrol carbine program, an officer safety issue and an obligation under the CLC, was accorded sufficient priority between 2007 and 2014.
“failure to comply with the Canadian Labour Code [sic] where police are confronted with incidents involving the threat of grievous bodily harm and or death”.
 It is clear that if RCMP management were not convinced in 2007 then by late 2010 or early 2011 they knew or should have known that there was a serious safety risk to front-line members when they faced heavily armed opponents and that this risk should be highly prioritized. The question then becomes what did RCMP management do to address this risk and does their conduct establish a breach of their duty of care to ensure the health and safety of employees while at work?
 Once the patrol carbine had finally been approved as an addition to inventory of firearms available to front-line members in September 2011 the RCMP decided on an incremental divisional rollout. The Divisions were provided with a tool by RCMP management in Ottawa designed to assist them in determining how many carbines they would need and in what areas they should be firstly deployed, the idea being that Detachments facing the highest risk should receive the carbines before Detachments where the risk was determined to be lower. As noted in paragraph 46 above, a portion of the tool dealt not with an assessment of risk, but questions relating to finances and budgetary approval.
 The RCMP knew that such a risk assessment was an inaccurate tool. In the preamble to the first risk assessment tool sent out to a sampling of Detachments it was stated: ”The policing environment has inherent risk, for this reason predicting where and when a lethal threat may transpire is not possible.” The evidence of Dr. J. Pete Blair, Professor Of Criminal Justice at Texas State University who was declared an expert in “training in police tactics, with an emphasis on police tactics in active shooter events” opined that it was “next to impossible” to predict where an active shooter event would occur by doing a broad based survey.
 Even allowing for the time required for updating IARD and IMIM policies and for developing and piloting a course of fire for carbine training, there was a significant time lapse before carbines became available for front-line members in New Brunswick. The rollout of the first 375 carbines was approved in July 2012 and yet nearly two years later none were available in Moncton. Even in January 2014 RCMP management personnel in J Division were greatly concerned with financial implications, particularly the cost of overtime in delivering carbine training. (Ex. 8, Tab 28). Consideration of officer safety does not appear to be included in discussions of the decision makers whether at Divisional or Headquarters level.
 While each individual step in the process may be justifiable at some level, when taken as a whole the length of time taken and the lack of urgency accorded the carbine project establishes, in my view, a prima facie case of breach of the duty of care required under section 124 of the CLC to ensure the health and safety of employees while at work.
 Having found a breach of the duty of care the onus now shifts to the RCMP to demonstrate on a balance of probabilities that, in this case, it had taken all reasonable steps to ensure the safety of front-line members when responding to active shooter events. Several factors come into play in this determination including the particular activity involved including inherent risks, the likelihood of harm, industry standards, relevant legislation, the promptness of the response to the issue, and mitigation efforts undertaken.
 The activity involved in this analysis is policing, and particularly the requirement that front-line RCMP members engage potentially heavily armed suspects. As has been already noted, it is beyond controversy that policing is a perilous occupation and sadly, as we know all too well, one in which danger of significant injury and/or death is present and can never be entirely eliminated. That does not mean that the risk should be ignored, nor does it mean that it must be accepted as being part of the job and therefore no efforts need to be made to reduce the frequency of risk or to mitigate the potential consequences of the risk or mitigate its occurrence.
 The RCMP suggests that the magnitude of the risk must be measured alongside its frequency. As I understand the submission, even though the risk is great because the likelihood of such an event is relatively remote, due diligence has been met. I am not attracted to that argument. If a risk of injury and death exists in the workplace, the fact that, happily, it does not occur frequently does not serve as mitigation of the risk. Due diligence cannot be reduced to a mathematical or statistical calculation where an employer can “take a chance” that because an event occurs infrequently, no, limited, or delayed action is an appropriate response. When the risk to the employee is great due diligence requires a robust and timely response.
“No one can hide behind commonly accepted standards of care if, in the circumstances, due diligence warrants a higher level of care. Reasonable care implies a scale of caring.
 In the case of general duty officers now required to initially engage heavily armed suspects there existed a grave potential of harm, although the likelihood of an incident in which death or grievous bodily harm actually occurred was statistically remote. While the RCMP could not control the causal elements in the sense of predicting or allowing the event to occur, there can be no question that they were aware of the increasing prevalence of heavily armed opponents and the presence of long guns particularly in the north and in rural areas. The 2007 Needs Analysis for Hard Body Armor (Ex. 1, Tab 5) prepared by Bruce Stuart, notes at page 5 that “there has been an increase in the possession of firearms by criminals within Canada, in particular ‘high power’ weapons.” and later “anecdotally, RCMP members face rifle and shotgun threats regularly, especially in rural areas.” That same report at page 4 referenced a document prepared two years earlier which had recommended the provision of HBA as the appropriate required level of protection for general duty members and noted “In fact, it is felt that the risk in this area has increased, rather than diminished”. Yet on June 4, 2014, HBA had only recently arrived at Codiac Detachment and most of the responding members were unfamiliar which its use.
 In my view the larger issue in determining whether or not the RCMP have established a defence of due diligence requires a consideration of the promptness of the RCMP response to the issue and the question of mitigation of risk in the interim period.
 The RCMP asserts that the time required for the rollout following the 2011 acceptance of the patrol carbine as an addition to the weaponry available to front-line members was necessary to allow for the governmental procurement processes they are required to adhere to, to allow their contract partners time to complete their own budgetary processes, and to prepare upgraded training and course of fire protocols.
 One year after approval by SEC the first contract for 527 carbines (that is the 377 ordered by Divisions after completion of their threat assessment matrix and an additional 150 ordered by E division), was awarded to Colt Canada. It was however another year, that is, in September 2013, before any patrol carbines were shipped from the RCMP Armourer to the Divisions, and even then only 22 carbines were shipped to J division. By June 4, 2014 there were no carbines available to general duty RCMP members in Moncton. Indeed it was not until June 6, 2014 that the first 13 J Division members were trained as patrol carbine operators.
 That is not to say that nothing happened in those thirty three months. The procurement process mandated by Federal government regulations was time-consuming and there were delays in obtaining some of the ancillaries because of problems with the manufacturer. There were training materials to be prepared, piloted and eventually rolled out. There were innumerable meetings of the Carbine Project Board and the Project Investment Board, minutes of meetings and reports drafted and circulated, apparently to satisfy the requirements of the bureaucracy at RCMP Headquarters in Ottawa.
 While individually each of these items may have been necessary, when one looks at the bigger picture there is nothing to suggest that RCMP management, either at National or Divisional level, felt a sense of urgency to move the project along. If, as RCMP internal documents state, the status quo was unacceptable in relation to the known duty to ensure the health and safety of general duty members, management’s actions in response to that duty do not demonstrate a resolve to address the issue in a timely manner. The focus throughout the process was on other concerns, some of which, such as budgetary issues, dealing with contract partners, and training were legitimate; while others, such as shielding themselves from public criticism, should not have been part of the equation.
 The timeframe for the rollout of any meaningful number of patrol carbines for general duty member use was a far cry from the eighteen months envisioned by Knecht in January 2011. I was impressed by Knecht who had some thirty four years of experience with the RCMP before assuming his current post. He struck me as a “straight shooter”, someone who wanted to get things done, and who had been frustrated by the bureaucracy in Ottawa. Although not in favour of patrol carbines for general duty use at first, when he “became educated on this” (as he put it), he changed his mind and called it an easy decision to make, but allowed that implementing it would not be quite as easy. Unlike many of the RCMP witnesses, he testified to feeling “a fair sense of urgency” in moving the project forward. I am inclined to accept his timeline of eighteen months before patrol carbines were on the street as reasonable.
 Assistant Commissioner Alphonse MacNeil (ret’d) was engaged by the RCMP to perform an Independent Review Moncton Shooting (Ex. 5, Tab 35) and also testified at trial. MacNeil served with the RCMP for thirty-eight years in a variety of capacities until his retirement in 2014. He was, by consent, declared an expert in “tactical, operational and strategic policing including RCMP operations, tactics, equipment, management supervision and training.” At page 170 of his Review, MacNeil stated “A full examination of the research, procurement and subsequent national rollout of the patrol carbine is beyond the scope of this report”, however because that weapon was not available to the initial members who attended the scene his review did touch on some aspects of the patrol carbine project.
 I agree with MacNeil’s conclusion. The rollout took too long, even allowing for all the variables and challenges noted above.
 The difficulty is that the “strategy” is no more than a suggestion and there is no evidence that it was either acted upon or implemented and certainly not by J Division. Indeed the evidence establishes that RCMP management in Ottawa took a “hands off” approach to the Divisional rollout. Deputy Commissioner Brenda Butterworth-Carr, who in August 2012 was the Director General of National Criminal Operations, testified that she was not in a position to direct how Divisions managed the Patrol Carbine rollout and was unaware of who would be in a position to order Divisions to undertake a mitigation strategy such as the one suggested in Pratt’s e-mail. Commissioner Paulson allowed that he could have given such a directive, however none was ever given.
 In my view the RCMP did not have, during what MacNeil referred to as the “protracted process of studying, procuring and delivering” the patrol carbine, a mitigation strategy in place to mitigate the risk to front-line members who were required to engage active shooters who may be armed with long barreled weapons. The risk was known to the RCMP and had been the subject of comment in both the Mayerthorpe and Spiritwood Inquiries (although neither specifically recommended the adoption of a patrol carbine) and was referred to in several RCMP Briefing Notes and reports previously noted.
“the potential long-term impact on its policing model of arming its general duty members with carbines, in particular the issue of the militarization of the police force” (Defence Final Submissions at par. 77).
“implementing policies and practices that render the C-8 military-grade machine gun standard issue to RCMP line-personnel along with military-grade body armor constitutes a significant movement down the militarization continuum”.
 What Dr. Kraska does not conclude is that the decision to so equip front-line members was either unnecessary or wrong. He describes it as a “cautionary tale” based on his statistics and research, all of which come from the U.S.A., which indicate the potential of unintended consequences to such decisions mainly relating to public perception of the police. He made frequent references to police shootings in Ferguson, Missouri and Dallas Texas, and to the erosion of public trust and police legitimacy in those cities. He offered no Canadian statistics and admitted that he had not studied the Canadian experience nor was he in a position to opine on them. While interesting, the evidence presented is of marginal use in determining any of the questions before the Court. He allows that there exists a quandary between the cultivation of a paramilitary culture among line officers by equipping them with carbines and leaving them ill prepared to effectively handle an active shooter situation by not so equipping them, suggesting the need to be “cautious, prudent and thoughtful” when making the decision. Being thoughtful, cautious and prudent however does not take precedence over the duty imposed by s. 124 of the CLC.
While this may in fact reflect the RCMP’s concerns in February 2017, I can find no reference in any of the voluminous material filed as exhibits, other than in Dr. Kraska’s report, of a concern expressed over militarization of policing.
 D/Com. Brosseau talked about the line of questioning regarding political/public support for purchase of carbines which is found in the Divisional Threat/Risk Assessment at question 15 along with whether there was financial support for the purchase at question 16. In Brosseau’s 2013 presentation to the SEC, the question of local political and public support is addressed in relation to the Threat/Risk assessment tool and not in any broad based concerns about militarization of policing. I can find nothing in the evidence which would lead me to conclude that concerns about militarization of policing was a factor in any of the RCMP actions in the rollout of the carbine up to June 4, 2017. It simply cannot be used as a post facto justification for the delay in making carbines available to front-line members. In my view, any concerns about public perception of or political support for the carbines project was borne out of a desire to insulate the force from the type of public criticism it had faced regarding its rollout of the CEW and not from a concern about police militarization.
 Due diligence required the RCMP to do what a reasonable person having a similar degree of knowledge and experience would do, in all the circumstances of the case. In this case the persons who were tasked with informing and making decisions regarding the patrol carbine and its rollout were police officers having a vast range of experiences, who knew, or should have known, the risks front line members faced, and who knew intuitively that they were outgunned. Even accepting the proposition that it was not until receipt of the FCE in 2011 that it was evident that an upgrade to existing weaponry was required, would a reasonable person have allowed that state of affairs to continue, so that on June 4, 2014 no carbines were available to front-line members in Moncton responding to a gun call? Would a reasonable person accept that, of the some seven hundred front-line members in J Division, a plan whereby in the first year twenty-two (or three percent) would be provided equipment which a study indicated was an appropriate solution to an identified firearm capability gap was appropriate? Would a reasonable person conclude that five years after the start of the carbine rollout in J Division it would be appropriate to provide that equipment to only seventy (or ten percent) of the front-line members? I think not.
 Due diligence, while not requiring superhuman effort, does require a plan properly prioritized, resourced and executed to address known risks to the health and safety of members, and in this case specifically, the known risk of death and/or grievous bodily harm to members when responding to an active shooter event. The plan to investigate the need for and thereafter the rollout of the carbines was under resourced from the beginning (despite repeated requests from Lightfoot and Madill for additional personnel at Use of Force Section), was badly managed (the Davies contract and the initial rejection of the CPRC as an appropriate research body), was not properly prioritized (firstly the CEW delay and then the decision to have a divisional rollout) and was lacking in any sense of urgency to have the plan completed.
“An approach which focused on likelihood of danger rather than on exclusion of danger where possible could encourage employers to engage in a chillingly brutal calculus of the odds of harm against the cost of its avoidance”.
While I do not suggest that the RCMP made such a calculation, it is clear that their approach to the rollout was focused on the odds of an event such as the Moncton murders ever happening, rather than on their duty to ensure the health and safety of its members should it happen. It is also clear that no one, and no threat assessment, can predict when such an atrocity will occur.
“Call ERT. We’re going to need everything we’ve got.” [And] “Keep cover guys. He’s got long guns. Ours are too short for him.” (Ex. 4, Tab 24, Session 16 & 17).
A couples of minutes later Cst. Nickerson, who has seen two of his colleagues murdered by the shooter and who obviously knows that armed only with his service pistol he is outgunned, asks MacLean “Do we still keep moving because again, he’s got the high power and he’s probably got a scope.” (Ex.4, Tab 24, Session 29) Cst. White, who while in the Canadian Armed Forces, had been qualified in carbine use, encountered the shooter on Bromfield Avenue and testified that if a carbine were available to him he could have effectively engaged him but he knew that the shooter was out of range of his pistol. Lastly Cst. Dubois, who was actually shot while rescuing Cst. Benoit and who had a visual on the shooter but at a distance beyond the range of his pistol, testified that, based on a lifetime of experience with firearms as a hunter and his RCMP training, he could have engaged the shooter if he had a carbine. I accept as accurate their observations as to the adequacy of the firearms at their disposal in responding to this active shooter event, and reject the proposition that they were adequately armed to respond to an assailant armed with a long gun.
 Almost all members of RCMP management who testified at trial said that safety of their members was a priority of theirs. While they paid lip service to that ideal their actions, or in this case inactions, belie that concern. A real concern for the health and safety of front line members responding to active shooter events would have seen a rollout of the patrol carbine prioritized and not left to the vagrancies of available funding. It would not countenance a plan for J Division where after five years only ten percent of front line members had access to equipment which their own studies determined was an appropriate solution to a demonstrated need, that is, that RCMP members are not adequately equipped to be able to deal safely and appropriately with some of the threats they face during their daily operations.
 I therefore have concluded that the Defendant has not established that it acted with due diligence and find the Defendant guilty of Count One.
“…failed to ensure the health and safety at work of every person employed by it, namely: Royal Canadian Mounted Police (RCMP) members, was protected by failing to provide RCMP members with appropriate information, instruction and/or training to ensure the health and safety of RCMP members when responding to an active threat or active shooter event in an open environment, contrary to Section 124 of Part II of the Canada Labour Code…”.
 There is no provision of the CLC or its Regulations which would require the provision of information, instruction or training in regard to either the members response or the supervision of members when dealing with an active threat or active shooter event which occurs in an open environment. Therefore the onus rests on the Crown to prove beyond a reasonable doubt that the omissions in Counts Two and Three are reasonable precautions that a reasonable employer in similar circumstances ought to have implemented in order to protect the health and safety at work of its employees. (R. v. Brampton Brick Ltd.  O.J. No. 3025 at par. 28). The Crown cannot discharge this burden by proving that the precautions they allege were not taken were reasonable in some abstract sense, but rather that they were reasonable in all of the circumstances of the case. The hazard sought to be alleviated must have been either actually or reasonably foreseeable. (R. v. Petro Canada  O.J. No. 4396 at pars 135-136).
 Defence Counsel suggests that there is no evidence that anyone in the RCMP anticipated outdoor active shooter events; however such an event occurred at Spiritwood in 2006. I reject the notion that it was not reasonably foreseeable that RCMP members could face an active shooter in an outdoor environment. In fact it was actually foreseeable. The RCMP position appears to be that as outdoor shooter incidents are relatively rare comprising, according to the MacNeil report, approximately ten percent of all North American incidents, then they are not reasonably foreseeable. That is not the case. It was foreseeable that another outdoor shooter event would occur; however the likelihood of it happening was remote.
The training provided (observing threat clues, using the seven stages of risk assessment, the seven tactical principles and the ten tactical errors), enabled responding officers to respond to the threat they faced. What they lacked however, was the appropriate equipment to deal safely and effectively with that particular threat.
 I agree with the findings of Kastner, J. in Petro Canada (Supra at par. 198) that an employer cannot be required to “provide” something that did not exist and that “the plain meaning of the word ‘provide’…does not include the concept of ‘developing’ or ‘inventing’.” My conclusion is that the precautions alleged in Count Two are not, in all the circumstances known prior to the tragic events of June 4, 2014, reasonable precautions which ought to have been taken.
 Defence Counsel in their final submission, and Paulson in his testimony referred to the MacNeil report as measuring the RCMP against a “standard of perfection”, presumably in regard to his recommendations that the RCMP provide training to better prepare supervisors to manage and supervise throughout a critical incident and that they include outdoor shooter response tactics in the IARD course. That is incorrect. What MacNeil said in his testimony was that he was not looking at some sort of gold standard but rather at what he believed could be achieved in a reasonable period of time.
 I have therefore concluded that the Crown has not established a prima facie case in respect of Count Two as the precautions particularized did not exist prior to June 4, 2014 and are therefore not reasonable precautions. In respect of Count Three, the Crown has failed to prove that the precautions alleged in that Count were precautions which the RCMP as a reasonable employer ought to have implemented for the protection of its employees. I find the Defendant not guilty on Count Two and on Count Three.
 Because of my decision on Count One I hereby enter a Judicial Stay of Proceedings in respect of Count Four.

References: v. 
 v. 
 v. 
 v. 
 v. 
 v.