Y2021-01 Elevator accident in a hospital in Kauniainen on 11 May 2021

In the afternoon of Tuesday 11 May 2021 in the Kauniala Hospital, an accident occurred in which a patient in a wheelchair died after getting caught between the elevator car and the elevator shaft. The mechanical brake of the elevator was stuck in the open position, and as a result, the elevator car started moving again after it had arrived at the floor. The cleaning and lubrication of the old brake mechanism was insufficient.

The elevator was commissioned in 1978, when ensuring elevator safety was based on mandatory monthly maintenance and monitoring by an authority. The elevator had been modernised in the 2000s, but its basic technical solutions remained the same. In addition, the elevator had been maintained much less frequently than in the original maintenance programme in recent years.

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 threshold for addressing the issue has become high, even though the importance of a maintenance programme for the safety of the elevator increases as the elevator ages. In the opinion of the inspection body, concrete evidence of insufficient maintenance must be found at the time of inspection in order to make it possible and justified to address the matter. However, the law does not prevent addressing it.

The safety features of elevators have improved over the years, and therefore elevator safety can be improved through renovation and replacement. Identifying the need for projects and starting them require good building management. There were deficiencies in it at the 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 supervision of health care authorities, even though the maintenance of challenging hospital buildings requires good building management and technical expertise.

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 elevator training of the rescue department did not discuss the possibility of a brake malfunction; it focused on other types of elevator accidents.

After the accident, there was a clear need for psychosocial support. Getting the support was not fully successful, however, because there were problems with the availability of social emergency and crisis services and occupational health care services. Psychosocial support was not realised in a sufficiently timely manner.

The Safety Investigation Authority recommends that:

• The Finnish Safety and Chemicals Agency develop procedures for preventing excessive cutbacks in elevator maintenance programmes and the delay of renovations. The inspection body must be able to inspect the maintenance programme, demand justification for any changes and address defects.

• The Regional State Administrative Agencies and the National Supervisory Authority for Welfare and Health (Valvira) ensure that public and private social welfare and health care operating units have an operating model, resources and a plan for long-term building maintenance. Building maintenance must be competent, systematic and sufficient in relation to the operations and the characteristics of the building.

• The Emergency Services Academy Finland and the partnership network of rescue departments ensure that the training material in the field of rescue includes instructions on how to identify a brake malfunction and prevent the movement of the elevator mechanically. The information must be provided to rescue departments.

In addition, the Safety Investigation Authority repeats the recommendation issued in two previous investigations, according to which:

• The Ministry of Social Affairs and Health shall ensure that there are plans, resources, defined responsibilities and competent, expert management available for the psychosocial support of serious accidents, regardless of where the accident occurs or where the parties are from. The goal is to ensure that everyone receives the individual and communal as well as practical support they need at the time when they need it.