Maintenance programmes for old elevators and building management of social welfare and health care operating units must be improved

The Safety In­ves­ti­ga­tion Au­thor­ity, Fin­land, has com­pleted the in­ves­ti­ga­tion into the ac­ci­dent that oc­curred in the Kau­niala hos­pi­tal on 11 May 2021, in which a pa­tient in a wheel­chair died. The el­e­va­tor brake was stuck in the open po­si­tion, and as a re­sult, the el­e­va­tor started mov­ing again de­spite hav­ing al­ready ar­rived at a floor. The in­ves­ti­ga­tion dis­cov­ered de­fi­cien­cies in the main­te­nance of old el­e­va­tors.

In May 2021, the Safety Investigation Authority notified the Finnish Safety and Chemicals Agency (TUKES), in a charge of elevator safety, the Ministry of the Interior and Rescue Departments about a threat of accident related to brakes of old elevators.

The elevator in Kauniala was manufactured and installed at the end of the 1970s, and it had been modernised in the 2000s. The elevator, and especially the brake that used old technology, had been maintained clearly less frequently than stipulated in the original maintenance programme, however.

“The practices of the authority in charge of elevator safety and the inspection body do not properly ensure that the maintenance programme is sufficiently comprehensive. The law does not prevent addressing the matter, but in the opinion of the inspection body, concrete evidence of insufficient maintenance must be found at the time of inspection. Based on the investigation, we recommend ensuring that the elevator maintenance programmes are not cut down too much and that the necessary renovations are not delayed. It must be possible to inspect maintenance programmes and address their shortcomings,” says Administrative Director Hannamari Helke, Safety Investigation Authority.

The investigation also found deficiencies in building management.

“There were deficiencies in the building management of the Kauniala Hospital, because there was a lack of technical know-how and many issues in the rental agreement had been left to be agreed upon later. Building management is not handled in the supervision of health care authorities, even though the maintenance of challenging hospital buildings requires good building management and technical expertise. We are addressing this issue, too, with the safety recommendation that has now been issued,” says Investigator-in-Charge Kai Valonen.

Three new safety recommendations are issued as a result of the investigation. The two recommendations that have already been mentioned address the defects in elevator maintenance programmes as well as the building management of public and private social welfare and health care operating units. The third safety recommendation is related to the fact that in the rescue activities after the accident, the brake being stuck in the open position came as a surprise to the rescuers and caused a risk of an additional accident. The training material in the field of rescue must include instructions on how to identify a brake malfunction and prevent the movement of the elevator mechanically.

In addition, one previously issued safety recommendation on providing psychosocial support after the accident is repeated as a result of the investigation.

Further information:

Investigator-in-charge Kai Valonen, tel. +358 2951 50707

Acting Executive Director, Administrative Director Hannamari Helke, tel. +358 2951 50713