Judicial Enquiry into the cause of death of Jeffrey Allan Wright, Sylvia Wright (born Fokeer), Toolsee Ram Ramdhari, Pravin Kumar Khoosye, Karmish Saligram Tewary, Dhanraj Saligram Tewary, Retnon Sithanen, Rabindranath Bhobany, Fan Lan Wong Tat Chong Lai Kim and Stevenson Henriette who died during the floods of 30th March 2013.
Following the enquiry carried out by the police into the cause of death of
1) Jeffrey Allan Wright;
2) Sylvia Wright (born Fokeer);
3) Toolsee Ram Ramdhari;
4) Pravin Kumar Khoosye;
5) Karmish Saligram Tewary;
6) Dhanraj Saligram Tewary;
7) Retnon Sithanen;
8) Rabindranath Bhobany;
9) Fan Lan Wong Tat Chong Lai Kim and
10) Stevenson Henriette,
the Office of the Director of Public Prosecutions instituted a Judicial Enquiry before the District Court of Port Louis on the 4th March 2014 pursuant to sections 111 and 112 of the District and Intermediate Courts (Criminal Jurisdiction) Act.
The proceedings started before the Learned Magistrate Mrs Ida Dookhy-Rambarun, on the 21st April 2014 and 97 witnessesincluding the relatives of the deceased, representatives of the Police Force, Fire Services, Mauritius Meteorological Services, Rapid Security Services, Caudan Security Services, Prime Minister’s Office, National Disaster Risk Reduction and Management Centre, the National Development Unit, the Ministry of Public Infrastructure and the Ministry of Housing and Lands were heard. CCTV footages of the events were also viewed. The proceedings were completed on the 15th July 2014. On the 29th December 2014, the findings of the Learned Magistrate were communicated to the Director of Public Prosecutions.
A. Background facts
The learned Magistrate established the following background facts:
(a) On the 30th March 2013, following the heavy flooding in Port-Louis, ten persons lost their lives. The bodies of six persons namely Jeffrey Allan Wright, Sylvia Wright (born Fokeer), Toolsee Ram Ramdhari, Pravin Kumar Khoosye, Karmish Saligram Tewary and Dhanraj Saligram Tewary were retrieved from the Caudan underpass. The bodies of Rabindranath Bhobany and Fan Lan Wong Tat Chong Lai Kim were retrieved from the underground parking of Harbourfront Building. The body of Retnon Sithanen was found in Company Garden while the body of Stevenson Henriette was found near KFC of Chaussée Street.
(b) More than 136mm of rain fell within two hours i.e. between 13h00 and 16h00. Members of the public were taken by surprise by the sudden downpour.
(c) The city centre is surrounded inland by a mountain range and because of the steep mountain slopes, the storm water generated reaches the foot of the mountain very quickly. The water crosses the city area in a very short time through the existing water courses to reach the sea.
(d) The Port Louis area between the Caudan Flyover and the Place D’Armes is drained by four main water courses namely the Deviation Canal which runs along Signal Mountain Road, the drain along Volcy Pougnet Street, Le Pouce Stream which passes behind Cinema Majestic and Le Pouce Canal which passes in front of the Museum and Shoprite Supermarket. These main water courses were completely flooded.
(e) After the flooding some 300 tons of debris and garbage were removed from the drains. The debris included mattresses, old fridge, iron sheets, plastic bags, bottles and vegetation.
(f) The cumulative effect of the deficient drainage system and the surface run-off generated with the urban area has contributed to the flooding.
B. Assessment of the role of various Government Agencies
The Learned Magistrate commended the assistance provided by officers of the Special Supporting Unit, the National Coast Guard, the Special Mobile Force, the Helicopter Squadron, the GIPM and the Fire Services. Based on the evidence in front of her, she identified a number of disturbing institutional failures:
(a) The Mauritius Meteorological Services (MMS)
The special bulletin of the MMS came relatively late when several places were already flooded so that there was little room for precautionary measures.
The absence of a weather radar presented a serious shortcoming in the weather monitoring system. The forecasters did not resort to other resources which were available such as the weather forecast of Reunion Island.
The MMS cannot vouch about the amount of rainfall that fell on Signal Mountain. An automatic Weather Station and a weather radar would have helped the MMS to give a more precise forecast.
The MMS is not equipped in terms of knowledge and skills to predict flash floods. The MMS alone with its data cannot forecast flash floods. Other Stakeholders like the Water Resources Unit, the Ministry of Public Infrastructure and Local Authorities need to provide their input.
(b) The Water Resources Unit (WRU)
Whilst the Water Resources Unit should be a major stakeholder for the forecasting of floods, it lacks required expertise in flooding.
(c) The National Disaster Operations and Coordination Centre (NDOCC)
The NDOCC was not equipped to deal with the flash floods of the 30th March 2013. The Cyclone and Other Natural Disaster Scheme 2012-2013 did not make any provision for flash floods.
(d) Police and Fire Services
The Police as well as the Fire Services faced communication problems on the 30th March 2013.
The telephone network was clogged and people could not reach the Fire Services. The Fire Services did not have sufficient manpower to deal with the situation.
(e) The Municipal Council of Port-Louis, the Ministry of Public Infrastructure (MPI), the Ministry of Environment and Sustainable Development and the National Development Unit
There was lack of coordination between the relevant Authorities as to the maintenance of several major drains. Due to lack of maintenance, some major cut-off drains have been reduced to a poor state and this has contributed to the major flood in Port-Louis.
Furthermore in some places the drains were unlined. In other places the drains have undergone physical damage and have not been repaired. The capacity of drains has been reduced due to pavement structure or vegetation growth. There are illegal constructions by the citizens on drains or by the side of existing drains.
A number of properties dispose of their roof and yard storm water on the road immediately in front of their premises.
C. Constructions and other obstructions in Le Pouce Stream and Le Pouce Canal
Structures on Le Pouce Stream and Le Pouce Canal which have been allowed by the Authorities have reduced the cross sectional area of the canals, for instance the construction of KFC building on Chaussée Street on Le Pouce Canal. The foundation of the building is on the drain and it creates an obstacle for the water flow. Similarly in respect of the covered spaces of Air Mauritius Parking, Rogers Parking, Hawkers palace and Garden Tower, columns have been cast on the river course.
The metal gate which has been placed on Le Pouce Canal near the museum hindered the flow of water. Pipelines of the Central Water Authority, Waste Water Management Authority and of the Mauritius Telecomwere found running across the water channels.
D. Causes leading to the death of the deceased persons
(a) Retnon Sithanen accidentally fell in Ruisseau Le Pouce and got swept away.
(b) Stevenson Henriette was carried away by the flood water and his body was stuck next to KFC Building of La Chaussée Street.
(c) In respect of the two casualties inside the Harbour front parking, there was heavy flow of water entering the parking and metal barrier had collapsed with the water pressure. Only one of the three accesses to the parking had been blocked by the security officers. The cameras inside the parking were not working. The water pumps were in working condition but were insufficient. The security officers had been taken by surprise and were not prepared for the situation.
(d) In respect of the six casualties inside the Caudan Underpass which was completely flooded, the Court highlighted that nobody expected the underpass to be submerged completely. The camera was defective. The water pumps were inadequate. The measure of having a security officer inside the underpass on a permanent basis for the security of the tenants and users was ineffective. The security officers failed to close the gates of the underpass in order to prevent people from acceding to it. The underpass was not equipped for flooding water.
E. Pertinent Observations by the Learned Magistrate
(a) There must be in place a weather radar in Mauritius as well as an Automatic Weather Station in the region where the rain fell on the 30th March 2013.
(b) The practice of the MMS must be revisited so that there is more proactive response if such situations arise in the future.
(c) The MMS should make maximum use of the data available from the weather radar from Reunion Island as well as other data which may be accessible on the internet, pending the availability of a weather radar. Forecasters should also bear in mind the general effects and consequences of climatic change worldwide.
(d) The MMS and the WRU must collaborate fully so that information is disseminated efficiently and in time to the National Disaster Risk Reduction and Management Centre.
(e) Mauritius must make appropriate investments in capacity building, technology development, social infrastructure and sustainability so as to be better prepared to face the phenomenon.
(f) There should be better maintenance of drains and better coordination between the relevant authorities in relation to the maintenance of drains.
(g) As per the recommendations of the consultants, all structures over the waterways must be removed to facilitate water flow.
(h) There must be an overall strategy to address the problem of flooding and there is a need for appropriate infrastructure for drains in Port-Louis.
(i) Awareness must be created amongst the public and the communication network must be strengthened. There should be an alarm system so that the public can be warned in a timely manner. The PIOR (Police Information Room) should be used to enhance timely coordination between all relevant bodies.
(j) Persons in charge of the security of the public should be given adequate training so that they are fully equipped to face the crisis. The framework within which companies offering security services operate must be revisited.
Office of the Director of Public Prosecutions
6th January 2015
[Editor: Highlights added]