This story originally appeared here and is republished by Carolina Public Press through a content-sharing agreement with The Charlotte Observer.
By Elizabeth Leland
When the Best Western Blue Ridge Plaza was built 14 years ago in Boone, billed as an eco-friendly hotel with breathtaking views, construction workers likely skipped some safety requirements.
Those shortcuts alone probably wouldn’t have threatened guests.
But a cascade of errors and random decisions since then led to an improbable and horrific result last year: Three people died in the same room.
Everything that could go wrong at the 73-room hotel did go wrong.
New testimony before an obscure state licensing board revealed more details about the circumstances that turned Room 225 into a death trap – from the judgment of maintenance professionals hired by the hotel to a seemingly innocent decision by a front desk clerk who didn’t know about the room’s lethal history.
The board held a heating contractor accountable for failing to detect obvious carbon monoxide hazards. It has filed a complaint against another contractor for wrongly converting the hotel’s swimming pool water heater from propane to natural gas.
That diffusion of responsibility could strengthen the defense of the one person criminally charged.
- Special report: Why did Jeffrey Williams die?
- Judge sanctions former Best Western employees
- 01.18: Mom who survived CO leak talks to ’20/20′
- 01.08: Hotel exec charged in Best Western deaths
Damon Mallatere, the hotel’s former manager, faces three counts of manslaughter. Daryl and Shirley Jenkins died of carbon monoxide poisoning on April 16, 2013, and 11-year-old Jeffrey Williams died on June 8, 2013. To convict Mallatere, prosecutors must prove he acted carelessly or recklessly and with disregard for the consequences. His actions also must have been “the proximate cause” of the deaths.
Mallatere’s attorneys said they would argue that negligence by others, including the two heating contractors, more directly caused the deaths than any negligence by Mallatere. A trial date has not been set.
The testimony before the State Board of Examiners of Plumbing, Heating & Fire Sprinkler Contractors came during a hearing in May to decide whether to suspend or revoke the license of contractor Dale Winkler of DJ’s Heating Services in Boone. The Observer recently obtained a transcript of the hearing.
In 338 pages of complex, yet compelling, testimony, Mallatere was the only person named who took specific actions that might have prevented Jeffrey’s death.
Series of missteps
For 13 years, guests stayed at the Best Western unaware of the hidden dangers.
Dale Dawson, executive director of the Board of Examiners, testified that problems likely dated back to the original construction in 2000.
Dawson said the exhaust pipe from the swimming pool water heater, which was designed to carry carbon monoxide outdoors, was improperly installed. He said openings to the fireplace in Room 225 were not sealed with fire-stopping material, as required by state code.
Those missteps laid the groundwork for what happened next.
Dawson showed the board photographs taken inside the hotel after the three deaths. The exhaust pipe was so corroded, it had gaping holes. He said the damage to the pipes probably was caused over time by a chemical reaction with chlorine used to kill bacteria in the pool.
The pipe ran above a dropped ceiling and was visible only when the ceiling tiles were removed. There was evidence that someone had been up there, working on the system, at some point: An ice bucket was propped up under one pipe; a VHS videotape supported an elbow fitting on another.
The corrosion, coupled with the holes in the fireplace on the floor above, allowed carbon monoxide to flow from the heater into Room 225.
A faulty conversion
The board also heard testimony about repairs on the heating system.
In October 2011, three maintenance workers replaced the existing pool water heater with a used Jandy heater from another hotel. They were not licensed to do the work and did not get a permit or ask for an inspection, in violation of the North Carolina building code. The Board of Examiners has barred all three from ever performing that type of work again.
The heart of the government’s criminal case against Mallatere rests on the replacement of the water heater. As president of Appalachian Hospitality Management, Mallatere managed the Best Western and five other Boone hotels and oversaw the maintenance workers.
There was no evidence presented that swapping out the heater caused problems. “It ran fine,” maintenance supervisor Harold Robinson testified.
The heater operated on propane. But, with natural gas becoming more available in the Boone area, businesses and residences were switching to the cheaper fuel. In February 2012, several months after the used heater was installed, Mallatere decided to switch, too.
He hired Independence Oil & Gas to convert the water heater at the Best Western. The contract specified that Independence would replace any appliance that could not be converted with new equipment designed for natural gas.
That didn’t happen.
Dawson testified that the manufacturer’s installation instructions specifically state that the heater could not be converted. Nevertheless, Independence did the conversion. A town building inspector approved the conversion despite the warning.
Why did they die?
A year later, Daryl and Shirley Jenkins checked into Room 225 on the floor directly above the heater. They had flown from their home in Washington state to visit cousins in a nearby mountain community and spent an uneventful first night in the room.
The next night, they died of carbon monoxide poisoning.
A police investigator speculated that on their first night the swimming pool water heater was running sporadically or not at all. The heater was controlled by a thermostat, and employees could manually adjust it when the water temperature dropped too low. Perhaps that’s what happened the night the Jenkinses died.
At the time, investigators surmised that the couple died from ill-timed heart attacks. “Broken-heart syndrome,” they called it. The rumor circulated around the small mountain town for weeks.
As the Observer reported in a Dec. 15 investigation, there was no sense of urgency among authorities to figure out what killed them. Firefighters did not check for carbon monoxide. Dr. Brent Hall, the local medical examiner, did not go to the death scene and did not ask for expedited toxicology tests. The Office of the Chief Medical Examiner took 40 days to complete the first test.
Even after carbon monoxide was pinpointed and the results emailed to Hall, the information was not released until after Jeffrey Williams died. Whether Hall read the email is not publicly known. He has declined all interview requests.
New testimony before the Board of Examiners revealed that, despite the inattention by authorities, Mallatere wanted to see whether anything in the hotel had harmed the Jenkinses.
Robinson, the maintenance supervisor, testified that Mallatere asked him to have someone check for natural gas leaks in two places: the fireplace in the room and the swimming pool water heater on the floor below.
Robinson called Winkler, and Winkler checked out the appliances. He discovered no natural gas leaks.
Then, according to testimony, Mallatere asked Robinson to have someone check to see whether the exhaust vent on the water heater was stopped up. Robinson called Winkler in again.
Winkler told the board he examined the heater. Then he went outdoors to where the vent on the exhaust pipe released carbon monoxide. He felt warm air coming out and concluded everything was working. Winkler told Robinson that if the hotel wanted to test for carbon monoxide, it would have to hire an engineer.
But, as Boone fire Chief Jimmy Isaac testified, no one suspected carbon monoxide.
A month later, Jeffrey Williams died and his mother, Jeannie, was seriously injured.
Are others responsible?
The Board of Examiners concluded that Winkler failed to recognize a number of problems: corrosion on the water heater; gasses drifting up from the exhaust vent when they should have been blowing out; and dangling wires that should have been connected to the heater so the power venter would draw the toxic gases outdoors.
The board ordered Winkler’s license be suspended at least a year for “misconduct” and “incompetence” in his inspection of the heater and in other jobs he did at the hotel. The board said he could get his license back only if he completed extensive training.
Winkler is appealing in Watauga Superior Court. A judge stayed the board’s ruling, allowing him to continue operating his business until the appeal is resolved.
Winkler could not be reached for comment. His attorney, Jeff Gray of Raleigh, called the board’s decision arbitrary, driven by publicity. “At the time of the deaths of the elderly couple, nobody had any suspicions except Mr. Mallatere,” Gray said. “All Mr. Winkler did was stop by and inspect (the swimming pool heating system) to see if it was running and working.”
The Board of Examiners also filed a separate complaint against Thomas Miller, a contractor with Independence Oil & Gas, the company that converted the propane heater to natural gas. Engineers who tested the heater after the deaths said it released abnormally high concentrations of carbon monoxide.
Miller’s case is expected to be reviewed in September. Details about the complaint won’t be made public until a decision is reached.
Dudley Witt, one of Mallatere’s defense attorneys, said the board testimony shows that nothing Mallatere did caused the deaths. “I would intend to argue that the negligence of Independence Oil, the town of Boone building inspector, Mr. Winkler and the medical examiner for Boone were the cause,” Witt said.
A fatal decision
Though testimony before the Board of Examiners provided some clarity, questions remain.
Why didn’t Hall, the medical examiner, go to the room after the Jenkinses died?
A maintenance worker testified about evidence Hall would have seen. Mark Atkinson, who had experience as an EMT, said he found vomit in the hot tub, where Daryl Jenkins died, and vomit near Shirley Jenkins.
“I was told that the man had a heart attack and that the woman saw him and had a heart attack,” Atkinson said. “I’ve seen people that had a heart attack, and they never vomit.”
Carbon monoxide can cause vomiting.
Testimony by a second hotel employee helped clear up a different mystery: Why did the Best Western rent the room before the medical examiner determined how Daryl and Shirley Jenkins died?
Sonya Newberry, the assistant general manager, said management intended to keep it vacant unless the hotel was sold out, both out of caution and out of respect for the Jenkins family.
A newly hired front desk clerk was working the night Jeannie and Jeffrey Williams checked in. After Jeannie Williams complained their room smelled of cigarettes, the new clerk upgraded them to Room 225.