Two months ago Saturday, the helicopter carrying Tiffany Hanna and Scott Puillandre went down. Confusion and a lack of communication lead to chaotic moments that morning.
The first report examining the crash and the response time was released late Friday afternoon.
While investigators still don't know what caused the helicopter to fall so quickly from the sky, there is a clearer picture of what happened on the ground in the moments after.
The report says the day flight instructor Tiffany Hanna died several things went wrong.
The helicopter crashed at 11:32 am. While police knew the exact location at 11:35 am it wasn't relayed to firefighters or paramedics until twelve minutes later.
The initial fire dispatch call was sent to the Wilmot fire station instead of Woolwich where the crash happened.
A new airport fire truck, purchased for a million dollars, had to drive through a slow-moving access gate to get to the scene and was damaged in the process.
An Ornge air ambulance was initially called in but because a ground ambulance was less than ten minutes away it was intentionally delayed, and not put into the air, until regional paramedics arrived on-scene to determine the seriousness of the victim's injuries. Ornge has since reversed its policy of not responding immediately.
The report identifies emergency communications as a major concern. There are currently four separate 9-1-1 dispatch systems. For years the region has studied the logistics of consolidating the systems into one -- but hasn't had the technology, money, or provincial go-ahead to do it.
Council received a report about the challenges as recently as a month before the crash.
Despite the problems E-M-S says Tiffany Hanna's injuries were so severe she died just moments after the crash, and there was little chance of saving her life. Council is set to discuss this report on Tuesday.
One of the major recommendations is to move all of the emergency dispatch services into one location. Right now they're in different buildings and use different software.
Retired Waterloo Regional Police chief Larry Gravill wrote the official review released Friday.