Incident Investigations

As part of Technical Safety BC's commitment to share safety information with clients and the public, we share our incident investigation summaries. The investigations are documented in our enhanced incident investigation report format and organized by technology.

When does Technical Safety BC investigate?
  • When regulated work or regulated equipment is involved
  • When evidence is available to help determine causes and contributing factors
  • Where a learning opportunity exists to understand and document what caused the incident, and to inform prevention of similar incidents.
When does Technical Safety BC not investigate?
  • Where a regulated product or work is not involved
  • Where there is no evidence of regulated equipment being involved, or it has been ruled out.
  • It does not meet the definition of an incident
  • Evidence of cause or contributing factors is poor or non-existent.
Title Ref # Incident Date Technologies Publish Date
Refrigeration system: Residual ammonia released from the oil separator causes emergency shut down II-745207-2018 (#8593) Boiler, PV and Refrigeration 6 June 2019
Natural gas system: 5 adults and 3 children exposed to carbon monoxide II-814368-2019 Gas 6 June 2019
Natural gas system: Damaged unit heater and venting system II-774658-2018 (#9731) Gas 6 June 2019
Low voltage electrical system: Heater and element tube has been destroyed #II-802909-2019 (#10709) Electrical 6 June 2019
Refrigeration system: Ammonia leaking through pinhole in evaporative condenser coil #II-743812-2018 (#8558) Boiler, PV and Refrigeration 6 June 2019
Refrigeration system: Rubber gasket failed #II-723226-2018 (#8084) Boiler, PV and Refrigeration 5 June 2019
Natural gas system: 2nd degree burns to hands, and face #II-757768-2018 (#9165) Gas 5 June 2019
Electrical: Low voltage electrical system arc and heat damage #II-812735-2019 (#10824) Electrical 5 June 2019
Refrigeration system: High pressure ammonia line valve failed #II-754551-2018 (#9026) Boiler, PV and Refrigeration 5 June 2019
Refrigeration system: Heat exchanger tube failure #II-749858-2019* (#8752) Boiler, PV and Refrigeration 5 June 2019
Passenger Ropeways: Impact damage to the front forks of a mountain bike #II-800508-2019 (#10589) Passenger Ropeways 5 June 2019
Electrical: Fire damage to an electric exhaust fan II-773843-2018 (Incident ID: 9705) Electrical 5 June 2019
Electrical: 3 Phase 400 Amp load centre buss and associated over current devices disintegrated #II-760614-2018 (#9226) Electrical 5 June 2019
Elevating Devices: Loose evacuation drive control cable sheath # II-657810-2018 - 6044 Elevating Devices 5 June 2019
Passenger ropeways: Passenger stranded on gondola lift line #II-711375-2018 (#7217) Passenger Ropeways 5 June 2019
Amusement Devices: rider complained of whiplash and bruising on her right side of her body while the co-rider had back pain II-694728-2018 (7408) Amusement Devices 5 June 2019
Elevating Devices: Head laceration and broken finger #II-664312-2018 (#6328) Elevating Devices 5 June 2019
Amusement Devices: Neck strain (headache, stiff neck) to 2 of riders #II-705299-2018 (#7610) Amusement Devices 5 June 2019
Elevating Devices: Elevator passenger hit head on the wall opposite the elevator #II-746278-2018 (#8544) Elevating Devices 5 June 2019
Worn roller guides likely the cause of minor elevator injury II-654906-2018 (5866) Elevating Devices 16 May 2019
Incorrect upthrust track specification setting causes escalator steps to pile into combplates II-674065-2018-2018 Elevating Devices 1 May 2019
Design flaw in oven range causes gas ignition flashback with resulting injuries #II-741521-2018 (#8524) Gas 26 April 2019
Technician inhales ammonia during maintenance of ice rink compressor II-700086-2018 (#BPVII-1141825) Boiler, PV and Refrigeration 23 April 2019
Ruptured refrigeration evaporator releases ammonia resulting in extensive area evacuation II-762099-2018 Boiler, PV and Refrigeration 19 March 2019
10-year old falls 4-5 metres from triple seat chairlift II-691314-2018 (6506) Passenger Ropeways 1 March 2019