Elevator emergency exit drop ceiling panel comes loose, falls and injures occupant

Persona

Technologies

Technologies
Reference number
II-684356-2018

Incident overview

Ceiling panel

While the elevator was in use, with an individual inside, the emergency exit drop ceiling panel became loose and fell from the ceiling injuring the occupant.

Regulated industry sector

Elevator

Location

Surrey, BC

Investigation conclusions

Site, system and components

The metal emergency exit ceiling panels in an elevator are held in place by two means of suspension. First the primary means of suspension is four screws that slide into a slot on the panel. Second is a bracket system, which consists of a metal bracket on either side attached to the panel with two bolts this keeps the panels from falling, If the Primary means of suspension fails the secondary would catch the panel and keep it from falling more than approximately 12 inches.

Failure scenario(s)

Due to the primary means of suspension becoming loose from regular vibrations in the elevator and the secondary means of suspension never being attached to the panel, it was able to vibrate itself loose and fall out of place.

Facts and evidence

During investigation, it was found that :

  • The secondary means of suspension was found in the elevator attached to the panel bars. The secondary suspension was observed to be not attached to emergency exit ceiling panel.
  • The emergency exit ceiling panel was placed back in the position it would have been before the incident, the drop ceiling was then lightly shaken to imitate the vibration of the elevator. Upon shaking of the drop ceiling the panel then fell out and crashed to the floor confirming the incident.

Causes and contributing factors

The cause for the emergency exit drop ceiling falling was most likely due to the secondary means of suspension not being installed during initial installation. It is very likely the natural vibration of the elevator over time was a contributing factor to the panel shifting and falling.

  1. Primary suspension loosened due to the vibration over time.
  2. Secondary suspension was never installed to hold the panels in place.

Impact

  • Injury
    • Qty injuries: 0
    • Injury description: N/A
    • Injury rating: N/A

Damage

  • Damage description: A receptacle and surge protected power strip were destroyed in a fire located in the bedroom of a residential unit in a multi-family building. Minor fire and smoke damage to the bedroom wall.
  • Damage rating: Moderate
  • Incident rating: Moderate
Attachment Size
G 7090-684356 (3-DE-2018).pdf 314.31 KB