Kauniala lift accident caused by a faulty brake – Tukes issues several recommendations for lift maintenance

The Finnish Safety and Chemicals Agency (Tukes) has completed its investigation of the lift accident that occurred at Kauniala Hospital on 11 May 2021. In the accident, the lift car started moving while the doors were still open, leading to the death of one person. The cause of the accident was a faulty brake in the lifting mechanism. To prevent similar accidents from recurring, the Tukes investigation team proposes lift maintenance recommendations for lift maintenance companies, lift owners and inspection bodies.

The immediate cause of the accident was a faulty brake in the lifting mechanism.
The brake was mechanically jammed in the open position and was unable to hold the lift car in place at the floor level, as a result of which the car started moving upwards pulled by the counterweight. Lift maintenance is highly important considering the reliability of the brake in the specific lift type’s lifting mechanism.

The investigation team proposes the following measures to avoid similar accidents and improve lift safety.

• Special attention must be paid to the maintenance of the lifting mechanism brake in Valmet Schlieren lifts. During every maintenance visit, it is necessary to inspect the free movement of the shaft of the brake’s electromagnet and, if required, to clean and lubricate the shaft and its slide bearings.
• The lift maintenance company and lift owner must ensure that the lift maintenance programme is lift-specific, sufficiently addressing the special characteristics of the lift in question. The maintenance programme must define the measures to be carried out during maintenance in sufficient detail. The number of maintenance visits must be sufficient.
• Lift maintenance companies must ensure that the measures defined in the maintenance programme are carried out during maintenance visits. Maintenance must address the type-specific measures required for different lift types. Maintenance measures must be carried out in accordance with lift-specific maintenance instructions.
• During periodic safety inspections, inspection bodies must inspect that a lift’s maintenance programme is suitable for the lift in question. The assessment of suitability must, to a sufficient extent, address lift-specific factors, such as the lift type, special features, the technology used, operating conditions, and any faults identified during operations.
• Rescuers are at risk if the lift car’s movement cannot be controlled during rescue operations. Instructions provided for rescuers should point out that, in these cases, the movement of the car can be prevented by securing the lift’s suspension rope to the pulley by using the rope pressing device available in the machine room. In general, it should be noted, in instructions provided for rescuers, that there is a broad range of lifts with different structures and operations.

Investigation report (pdf, 1,5 Mb, in Finnish)

Slides (pdf, 811 kb, in Finnish)

Further information:
Antti Savola, Senior Specialist, tel. +358 29 5052 684
Email: [email protected]