The sole survivor of a boat crash on Sudbury’s Lake Wanapitei phoned 911 to get help for himself and his three friends but instead wound up enduring an hour-long rescue effort on the line with a dispatcher who struggled to figure out his location despite being sent a map that pinpointed it through GPS.

Over the course of that hour, as Rob Dorzek held his unconscious girlfriend in his arms, the dispatcher instructed him to start a signal fire that accidentally spread in the dry conditions, igniting the boat and killing his friend, Michael Kritz, as Dorzek attempted to stanch the flames.

The events chronicled in an internal government report obtained by the Star and recounted by family members, a survivor and officials have raised startling questions about the effectiveness of the response to the boat accident on June 30, 2013, that ultimately claimed the lives of three young adults.

An internal report from the Ministry of Health and Long-Term Care documents a timeline rife with confusion and delays, noting there were “communication issues” between the branches of emergency response throughout the call.

Nickel Belt MPP France Gélinas, who represents that area of Sudbury, said the accident has left a lot of people feeling they cannot count on 911 for help. “We need to reassure people that, no matter where you live, when you dial 911 rescue will come.”

The families of the dead are calling for an inquest to determine what was done wrong — a request that the provincial coroner’s office is still deliberating. Dr. David Eden, the regional coroner for Sudbury, is expected to release a decision this week on whether he will call an inquest.

Stephanie Bertrand, 25, and Matthew Humeniuk, 33, died as a result of injuries from the accident. Kritz, 34, was killed when the small signal fire lit by Dorzek at the 911 dispatcher’s suggestion set nearby underbrush aflame and eventually reached the boat.

“We believe that if emergency services had not been contacted that night, it is very likely that there would have been more survivors of this accident, since according to the coroner’s report ‘but for the fire’ Michael ‘would most likely have survived,’ ” said Toni Kritz, Michael’s sister.

“This would obviously indicate serious flaws with the emergency response system in our area,” said Kritz. “We would therefore suggest that the public should be fully informed of the circumstances of the deaths in this case in order to make known, and thereby attempt to correct, the shortfalls of our current emergency services system.”

The Health Ministry report obtained by the Star includes recommendations such as enhanced training for dispatchers, more scripted questions to help them determine the location of a caller and a suggestion that local dispatch centres develop search-and-rescue plans with local agencies. The internal report commends the work of the dispatchers who handled the call.

Dorzek placed his first call to 911 at 12:30 a.m., according to the ministry report’s timeline. The rescue boat did not leave until 1:30 a.m. and was able to locate the accident scene in eight minutes.

In an interview with the Star, Dorzek said that within minutes of his first call he sent the dispatcher a picture from his phone of a map that clearly showed his location near the town of Skead, where a rescue boat was stationed. Yet rescue crews would not reach him for another hour.

“To anyone involved, even the volunteer firefighters who would have been involved, you show it to any one of them and just because they’re from that area, they know where that accident was, just from that blue dot on a big map,” said Dorzek, 29.

The four people were on their way to a party, having spent the evening together with drinks on one of the islands in the lake. Dorzek remembers seeing both Humeniuk and Kritz standing, looking over the windscreen before the boat struck a small island, less than 10 minutes from Tony’s Marina — a facility owned by Kritz’s family where the rescue boat was stationed. The pair were lifelong boaters.

“Everyone says the only reason they hit that thing they hit was because it was so dark. They were just a few feet more to one side than they should have been,” said Dorzek.

The coroner’s autopsy of the bodies found that Humeniuk, the driver of the boat, had a blood-alcohol level that “would be expected to cause substantial impairment and which significantly exceeded legal limits for operation of a boat.” Dorzek said he disagreed with the finding and that he did not feel unsafe getting in the boat prior to the accident.

Dorzek was knocked unconscious when the boat struck land. He came to inside the small front cabin. He tried to pull his girlfriend, Bertrand, out through a hole in the damaged boat. He was in frequent contact with the 911 call centre, located in downtown Sudbury, during the hour-long rescue effort, though the signal on his cellphone sometimes cut out.

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The dispatcher immediately scrambled two ambulances on land, according to the report, but Rob Hyndman, president of the Sudbury Professional Firefighters Association, told the Star that the fire crew needed to operate the rescue boat did not learn about the emergency from the dispatcher but through a chance encounter.

The force’s platoon chief that night, Terry Larocque, was at a burning house in another part of the municipality around 12:50 a.m. An EMS worker watching fire remarked to Larocque that he must be having a busy night and mentioned the accident on Lake Wanapitei. Larocque appeared not have heard about the accident through regular channels.

“(Larocque) is basically the senior officer responsible for the fire department on-shift,” said Hyndman. “He would have access to all the information of all the calls that are going on all throughout the city. Under the normal circumstances he would have had that information coming through his radio.”

Larocque immediately rallied the volunteer firefighters in Skead, said Hyndman.

Bob Humeniuk, Matt’s father, was among them but stayed on shore while others went out on the boat, Dorzek said.

The ministry report shows firefighters got to the rescue boat at 1 a.m. but were told by dispatchers not to leave until met by the paramedics. It took the paramedics another 20 minutes to find the rescue boat, according to the report. According to its chronology, the paramedics, despite being in the area since Dorzek’s call came in, had difficulty locating the marina.

“There were communication issues throughout the call between the allied agencies, such as fire communications not confirming that a fire boat was available in Skead and not providing information as to its location. When fire communications told (a dispatcher) at approximately 00:59 hours that the firefighters are at the boat launch, fire communications did not say where the boat was located and (the dispatcher) did not ask,” the report says.

Meanwhile, the dispatcher instructed Dorzek to start a signal fire on the island. He was still holding onto his girlfriend, Bertrand, who he had been trying to free from the boat.

“When (the dispatcher) demanded that I start the fire, I told her I can’t because it means I have to let go of Stephanie,” said Dorzek. “She insisted that was the only way we’re going to get help. That’s what she said. So I had to go do it.”

He took a cushion from the boat to the other shore of the small island and set it on fire. For a time the fire burned small and bright but then it spread to the underbrush. Dorzek tried to fight it back with a wet T-shirt but the flames reached the boat and the fibreglass hull quickly went up. He managed to pull Bertrand free, but Humeniuk and Kritz were still inside.

“That’s when the worst thing you’ll ever hear happened. For about an eight- to ten-second period, Mike (Kritz) screamed and then stopped,” said Dorzek. “Just moments later is when finally the fire boat showed up. The fire probably wouldn’t have been a bad thing if there were no delays, but even in this case they should never have talked me into turning the scene of an accident like that into the bonfire it turned out to be.”

The autopsy report of Kritz’s body found that he suffered a broken rib and contused lung in the accident — survivable injuries, according to his sister Toni.