note: for the protection of privacy this publically ... · note: for the protection of privacy this...

NOTE: for the protection of privacy this publically available document has been severed of the personal information of those involved in this incident and its investigation.

Major Incident Investigation Team

Report

Kennedy Lake Plateau Incident

October 19, 2010

Tofino Station 136, Unit 136K1N Prepared for: Les Fisher, Chief Operating Officer

Prepared by: Peter Yolland, Peter Gresty, Corey Viala, Garth Dinsmore,

Kevin D. Urton, Jim Fissel

The aim of the Major Incident Investigation Team (MIIT) is solely to identify the sequence of events leading up to the loss of the crew and unit of Tofino Station unit

136K1N; to identify any and all contributing factors related to the sequence of events; and to share all information with the BC Ambulance Service. It is not up to

the investigation team to determine or assign blame or responsibility for this incident.

Major Incident Kennedy Lake Plateau Incident Kevin D. Urton, Jim Fissel Investigation Team October 19, 2010 Peter Yolland, Peter Gresty Report May 2011 Tofino Station 136, Unit 136K1N Corey Viala, Garth Dinsmore

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EXECUTIVE SUMMARY

In the early hours of October 19, 2010, a British Columbia Ambulance Service (BCAS) ambulance crew dispatched from Tofino ambulance station (Station 136) was returning from a patient transfer at West Coast General Hospital in Port Alberni, B.C. At approximately 05:30 while driving along Highway #4 approximately 70 kilometers southwest of Port Alberni and at a location referred to as Kennedy Lake Plateau, Ambulance #62499 was involved in a single vehicle accident. The ambulance made contact with the roadside barrier, rode up and along the barrier until becoming overbalanced and rolled down a 33 metre embankment coming to rest in Kennedy Lake approximately 10 metres from shore submerged in approximately 10 metres of water.

At approximately 07:00, it was discovered by the Victoria Communications Centre that the ambulance had not returned to station and an extensive search was initiated. The accident site was found at approximately 08:40. Later it was determined that both crew members were in the vehicle and had died in the accident.

In accordance with BCAS policy and consistent with Division 10 of the Workers Compensation Act and following the guidelines and procedures outlined in the BCAS Occupational Safety and Health Training Program (Accidents and Incidents Investigation Module for Supervisors), an incident investigation was conducted and this report has been prepared.

An investigation team with representatives from the BCAS Management and Canadian Union of Public Employees local 873 conducted the incident investigation and prepared this report. The team was comprised of: Peter Yolland, Manager, Safety and Prevention, Kevin D. Urton, Professional Standards Unit, Superintendent, Lower Mainland, Peter Gresty, Regional Safety Advisor, Vancouver Island, Corey Viala, Provincial Safety Director, CUPE 873, Garth Dinsmore, Provincial Health Director, CUPE 873 and Jim Fissel, Director, Fleet Operations.

The MIIT believes that the actual cause of the accident will never be ascertained – no clear cause could be found.

Statement of Clarification At the time of submission, the Major Incident Investigation Team (MIIT) had concluded the investigation based on the most accurate information acquired. At the time, BCAS had not received a report from the BC Coroner’s Office or from WorkSafeBC (WSBC). Although not anticipated, it is possible due to their greater statutory authority that either the WSBC or the Coroner’s investigations may have had access to information that the MIIT did not have the opportunity to review. The MIIT has full confidence in its investigation, analysis and conclusions based on all the information obtained and reviewed.

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ............................................................................................................................. 3

FACTUAL INFORMATION .......................................................................................................................... 7

HISTORY OF INCIDENT ............................................................................................................................. 9

ACCIDENT SITE ....................................................................................................................................... 13

AMBULANCE: VEHICLE INFORMATION ............................................................................................... 19

GENERAL INFORMATION .................................................................................................................................19

DATA RECORDING SYSTEM(S) ..........................................................................................................................19

Tachograph .......................................................................................................................................... 19 Airbag Sensing and Diagnostic Module (SDM) .................................................................................... 19 Primary Engine Control Module (PCM) ................................................................................................ 20

VEHICLE MAINTENANCE/REPAIR HISTORY ..........................................................................................................20

Maintenance ........................................................................................................................................ 20 Transmission Repair ............................................................................................................................. 20 Tires...................................................................................................................................................... 21

MINISTRY OF TRANSPORTATION AND INFRASTRUCTURE POST CRASH VEHICLE INSPECTION REPORT ...............................21

AMBULANCE: COMMUNICATION SYSTEM INFORMATION ..................................................................... 23

Automatic Vehicle Location – VHF/cell ................................................................................................ 23 Cellular phone: Motorola KRZR # 250-720-5951.................................................................................. 24 Satellite phone: Iridium 9595A # 881651491387 ................................................................................. 24 Radios – portable, mobile, CAD............................................................................................................ 24 Global Positioning System: Garmin Nuvi 255w .................................................................................... 24 Pagers .................................................................................................................................................. 24

INTERVIEWS ........................................................................................................................................... 25

CONTRIBUTING FACTORS AND PROBABLE CAUSE .................................................................................. 43

AMBULANCE #62499 ....................................................................................................................................43

EMPLOYEE CAPACITY AT TIME OF ACCIDENT ........................................................................................................43

Underlying Health Considerations ....................................................................................................... 43 Education/Training .............................................................................................................................. 44 Driving History ..................................................................................................................................... 44 Employment History ............................................................................................................................. 44 Falling Asleep or Fatigue ...................................................................................................................... 44

EXTERNAL FACTORS ........................................................................................................................................45

Weather Considerations ...................................................................................................................... 45 Road Condition and Configuration ....................................................................................................... 45 Distraction ............................................................................................................................................ 46 Speed.................................................................................................................................................... 46 Visibility ................................................................................................................................................ 46

CONCLUSION - FINDINGS ....................................................................................................................... 47

RECOMMENDATIONS ............................................................................................................................ 49

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FACTUAL INFORMATION

Organization: British Columbia Ambulance Service

Community: Tofino

Station: 136

Incident Date: October 19, 2010

Incident Time: Approximately 05:30 hours

Incident Location: Kennedy Lake Plateau, Highway 4

Fatalities: Two BCAS Employees

Incident Type: Motor Vehicle Incident

Other(s) Involved: None

Organizational Unit

Designation: 136K1N

Vehicle Type: Ambulance, Crestline, Type 3 Mini-Mod

Vehicle Model: Ford E-350, Diesel, Unit 62499

BCAS Employees: Jo-Ann Fuller, Unit Chief, Primary Care Paramedic, Driver Ivan Polivka, Primary Care Paramedic, Passenger

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HISTORY OF INCIDENT

At 01:29, October 19, 2010, BCAS Victoria Communication Centre (Dispatch) was contacted by BC Bedline to accept a routine transfer of a sedated psychiatric patient to be transported from Tofino General Hospital to St Joseph’s Hospital in Comox, BC. Ultimately the transfer was split between two crews; Tofino (136K1N) to West Coast General Hospital in Port Alberni, BC and another crew from Parksville, B.C. (130K1N) to transfer the patient onto Comox. Dispatch had extensive conversation with the nursing staff at the hospital related to the nature of the patient, the level of sedation and the availability of a nurse escort to accompany the BCAS crew. It was determined that no escort was available and that the level of sedation was adequate to allow for safe transport. Dispatch also identified the need to do a patient switch in Port Alberni as Tofino Station was scheduled to do a transfer at 07:00. Part-time Unit Chief (U/C) Jo-Ann Fuller (covering for another crew member originally scheduled for this shift) and Paramedic Ivan Polivka were scheduled to work the night shift of October 19, 2010. U/C Fuller had worked a long transfer from Tofino to Nanaimo the day before that was initiated at 11:30 with the crew clearing station at 20:20. The night crew for Tofino station, 136K1N, were paged and responded to Dispatch by 01:38. In her response, U/C Jo-Ann Fuller expressed concern related to the scheduled transfer at 07:00 and her ability to staff a car to service the community while on this call. Due to the nature of the call, lack of escort and the concerns expressed, the Emergency Medical Dispatchers (EMDs) working at the time discussed the concerns and determined that the “transfers gotta be done”1. Dispatch informed Jo-Ann that a car would meet them in Port Alberni to take charge of the patient for the rest of the transfer to Comox. Dispatch informed Jo-Ann on the nature of the call and requested when she arrived at hospital to conduct a risk assessment and to let Dispatch know the result of that assessment. 136K1N did not contact Dispatch related to the assessment of the patient. The Tofino crew left Tofino Hospital at 02:29. Dispatch paged and spoke to the 130K1N crew from Parksville to arrange the meet with 136K1N to transfer the Tofino patient from one unit to the other at West Coast General Hospital in Port Alberni.

1 Transcription of Dispatch October_19_2010_02.04.14_136K_conversation_with_EMO_E100365704

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136K1N was contacted by Dispatch at 03:37 and 04:00 to get location updates. At 04:00 136K1N indicated that they were seven minutes outside of Port Alberni. At 04:09, 130K1N indicated that they had arrived at West Coast General Hospital and at 04:20 136K1N indicated to Dispatch they were clear, returning to quarters. Through testimony of the 130K1N it was determined that 136K1N arrived very shortly after they did and that the transfer was completed without incident at approximately 4:20am. In addition, the interaction between crew was very positive and by all indications, Jo-Ann Fuller and Ivan Polivka were alert and had a positive interaction. 136K1N cleared the hospital and proceeded toward the Tofino Station. The Automatic Vehicle Location (AVL) System ‘pinged’ (sent an automated locator signal) to the vehicle at an approximate location west end of Sproat Lake at 04:49. That was the last contact with Ambulance #62499 prior to the discovery of the accident site at Kennedy Lake Plateau. Two separate community witnesses who saw the ambulance between five and 15 minutes east of the accident site came forward later and testified. They each provided information about 136K1N; road conditions, the weather conditions, the amount of other vehicle traffic and road conditions. While en-route to the Tofino Station, 136K1N was involved in a single vehicle accident approximately 72 kilometres southwest of Port Alberni. The ambulance contacted the retaining wall on the north side of the highway, climbing up the wall and sliding along the top until overbalancing and crashing down the 33 metre embankment, coming to rest in Kennedy Lake approximately 10 metres from shore and 10 metres under water. The following is the timeline of the incident based on Dispatch records. October 19, 2010

01:29 BC Bedline call to Emergency Medical Dispatch (EMD) booking transfer of a medicated, psychiatric patient to St. Joseph`s Hospital in Comox.

01:36 EMD interconnect page to Station 136 kilo night crew (Jo-Ann Fuller and Ivan Polivka)

01:37 1st 136 kilo crew member confirms page (Jo-Ann Fuller).

01:38 2nd 136 kilo crew member confirms page (Ivan Polivka)

02:02 136 kilo crew member (Unit Chief) says cannot staff second ambulance to be available in the community - 136 kilo 2.

02:04 EMD to 136 kilo (Unit Chief) confirms that the transfer has to be done.

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02:29 136 kilo 1 nights (136K1N) departs, with Jo-Ann Fuller driving to Tofino Hospital 136K1N operating Ambulance # 62499 with patient to meet crew from Parksville (130K1N) outside Port Alberni Hospital to transfer patient. 130K1N to complete transfer to Comox. Dispatch asked 136K1N to advise when at Tofino/Ucluelet Junction.

02:52 136K1N to EMD they will be at Junction in 2 minutes.

02:53 130K1N paged to meet 136K1N.

02:53 1st 130K1N member confirms page.

02:54 2nd 130K1N member confirms page.

03:37 130K1N calls EMD advising they are arriving into Port Alberni.

03:37 EMD calls 130K1N but transmission inaudible.

04:00 EMD calls 136K1N advising that 130K1N is waiting outside Port Alberni Hospital.

04:09 136K1N advising EMD they are at West Coast Hospital and patient transferred to 130 kilo crew.

04:20 136K1N is 10-8 from Port Alberni hospital with Jo-Ann Fuller driving and Ivan Polivka in the passenger seat. Indicated 136K1N available. AVL signal received in Dispatch.

04:50 Last AVL signal received from 136K1N. Last AVL signal on vehicle was near the west end of Sproat Lake approximately 30 kilometers out from the hospital, at 04:50.

05:43 130K1N to EMD they are clear St. Joseph`s Hospital.

07:00 EMD pages 136K1N for transfer

07:03 Crew member at Tofino Station 136 calls EMD asks if he got a response from the page.

NOTE: This starts the multijurisdictional search for 136K1N. This process of the search, locating and responding to the accident scene falls outside of the scope of this MIIT investigation and report.

Based on the average driving times and speed in relation to the distance from Port Alberni to the accident location scene, the distance from the last AVL signal location, the timing and location of eyewitnesses who saw Ambulance # 62499 on the

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highway just preceding the accident location, it is the estimation of the MIIT that the accident occurred at approximately 05:30 on October 19, 2010. The following chart (Figure #1) provides a graphical representation of the events up to the time of the accident.

Figure #1

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ACCIDENT SITE

BCAS Ambulance #62499 was travelling southwest on Highway #4 between Port Alberni and Tofino. At approximately 05:30 it reached the area commonly referred to as Kennedy Lake Plateau 72 kilometers from Port Alberni. (See Figure #2) Figure #2

This section of the Highway #4 runs primarily in an east-west direction. [RCMP], in the Collision Analyst Investigation Report (CAIR), describes the highway and accident scene as follows:

Highway # 4 is an arterial highway constructed of asphalt that was found in good repair and well worn with use. At the scene Highway # 4, has one lane westbound and one lane eastbound. The travel lanes are separated by a double solid, yellow line. On the double solid line, a wake up strip has been ground into the asphalt. At the scene the highway, is a winding road that has a steep drop down to the Kennedy Lake on the westbound side. The eastbound travel lane is bordered by a vertical rock face that rises from the edge of pavement. There are no shoulders for the west or eastbound travel lanes. The westbound travel lane is edged from the steep drop off by two different styles of concrete barriers. The concrete barrier east of the crash scene had recently been upgraded to the newer sectional concrete barrier. This newer style barrier was measured to be 0.69 meters in height and is locked together with heavy steel hooks. The older section of concrete barrier was constructed in 1968. This barrier is part of the concrete wall that was built to allow the roadway to proceed out and around a rock face. At the start of this older style barrier, it was found to be 0.70 meters high. At this point, the westbound travel lane was measured to be 3.61 meters wide. (See Photo #1) Highway # 4 then makes a slight curve to the right and the westbound travel lane narrows to 3.17 meters wide. This travel lane narrows as the concrete barrier was not built to conform to the curve. The concrete barrier at this point, is 0.37 meters high.

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The road surface was constructed of well worn asphalt. The asphalt travel lanes were marked and gouged from rocks that had fallen or had been scaled from the vertical rock face that edges the eastbound travel lane. None of the gouge marks found on the road surface were fresh in appearance.2

Photo #1

It is important to note that preceding that section of Highway #4 are a number warning road signs that indicate that speed needs to be reduced to 30 km per hour (reinforced on three separate signs), that the road becomes very curvy, that the roadway narrows and that the road has overhangs that may require trucks to pass wide. There is no signage preceding the accident site that warns of falling debris. Observations by the Collision Reconstructionist in his report identified the travel lanes as marked and gouged from rocks that had fallen or had been scaled from the vertical rock face that edges the eastbound lane. When approaching Kennedy Lake Plateau from the east, the highway climbs up hill and turns sharply to the left and right that affects visibility of on-coming traffic. The section of highway where the accident occurred slopes slightly downhill with a series of right and left hand curves. At the location of the accident site there is a 33 meter cliff dropping from Highway #4 to Kennedy Lake below and immediately adjacent on the other side of the road is a rock face extending up from the road approximately 30 meters. The cliff face down to the lake has low shrubs and rocks but no large trees. See Photo #2.

2 Collision Analyst Investigation Report – pg 4

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Photo #2

Corporal Ferguson, RCMP, in the Collision Analyst Investigation Report (CAIR) describes the section of accident site as follows.

The road conditions at the crash scene are hazardous at the best of times. It is narrow with no shoulders. There are several curves, several of them blind. The roadway will not allow some large trucks to negotiate many of the blind curves without traveling out into the oncoming travel lane. There have been sign improvements with the addition of traffic warning signs, advising both east and westbound traffic of the narrow roadway, along with advisory speed signs for the curves. There has also been some improvement to the road by way of replacing the older “pour in place” concrete barrier with a higher concrete no post which has allowed for the road to be widened a little. The only place where the road improvement has not been done is at the location where the driver of the ambulance crashed into the “pour in place” concrete barrier. This barrier was measured to be 0.70 meters high where the first contact mark was found on the face of the concrete barrier. At the second contact with the concrete barrier, the barrier was measured to be only 0.37 meters high. This contact was made by the right front wheel of the ambulance as it climbed up onto the top of the concrete barrier. The next contact was made by the right rear as it climbed up onto the concrete barrier. The ambulance proceeded along the concrete barrier with the right side tires over the edge of the barrier. The ambulance proceeded along the top of the barrier, scraping and gouging the top. The scraping and gouge marks stop near the end of the concrete barrier, at which point the ambulance tipped to the right off the barrier, tumbling down the embankment.3 See Figure #3

3 Collision Analyst Investigation Report – pg 11

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Figure #3

The following pictures (Photo #3 and Photo #4) clearly show where the right front wheel and lug nuts made contact with the concrete barrier, the ambulance slid across the barrier before losing its balance and falling off the barrier.

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Photo #3

Photo #4

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Photo #5 provides a strong visual of the extent of the cliff that Ambulance #62499 traversed after leaving the road.

Photo #5

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AMBULANCE: VEHICLE INFORMATION

General Information

The Ambulance #62499 is a 2004 E350 Ford chassis, VIN# 1FDWE35P64HB36896 and License Plate 7692HY. The chassis was fitted with an ambulance box built by Crestline Coach Ltd. This ambulance was originally assigned to the Chase Ambulance Station in 2005, in late 2007 it was refurbished and in early 2008 assigned to Tofino and operated till the Motor Vehicle Incident at Kennedy Lake Plateau.

Data Recording System(s)

Tachograph

The ambulance had a Tachograph installed which was manufactured by Road Safety International. This RS-3000 tachograph, commonly called a “black box”, is a computer that monitors Speed, Strobe Light Circuit, Siren, Headlights, Brake Light, Right Turn Signal, Left Turn Signal, Overdrive Cancel Switch, Windshield Wipers, Horn, RPM, Flashing, Lights, Rotary Lights and vehicle G-forces caused by rapid accelerations, hard decelerations and high speed turns. It is not a water tight unit as is found in airplanes but is meant as a tracking and behaviour modification unit. The RS-3000 tachograph installed in Ambulance #62499 was removed by Corporal Ken Ferguson of the RCMP Collision Analysis & Reconstruction Service, Island District, 727 West Island Highway, Parksville, BC. Corporal Ferguson then sent the tachograph to the manufacturer, Road Safety International, Inc. in California. Road Safety International was not able to retrieve any data off the devise as a result of the unit being submerged while powered on. No data has been received by BCAS MIIT from the tachograph for inclusion in this report.

Airbag Sensing and Diagnostic Module (SDM)

The SDM was originally seized by the RCMP as part of their investigation. After an attempt at downloading they determined they did not have the correct program to download the information from this module. This module provides information on use of seat belts and deployment of airbags. WSBC then seized the module from the RCMP and attempted to download the information themselves. No data has been received by BCAS from WSBC for inclusion in this report.

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Primary Engine Control Module (PCM)

On January 13, 2011 the Primary Engine Control Module (PCM) was removed from Ambulance #62499. The control module was then turned over to a technician at the Knighthill service centre to have the data downloaded. The only data downloaded from the PCM was an Error Code that identified a battery interruption that would have been anticipated with this type of accident. This device was designed to retain engine fault codes and no other codes were found in the memory chip. No data was received from Ambulance #62499 and thus not included in this report.

Vehicle Maintenance/Repair History

Maintenance

The BCAS maintains its ambulances to a higher maintenance standard than those identified in the Ministry of Transportation and Infrastructure Commercial Vehicle Inspection Program (CVIP), through BCAS’s Preventative Maintenance Program (PMP). The maintenance program and standards are set in the BCAS PMP. BCAS selects, trains and routinely audits Service Centres province-wide to perform these maintenance functions. Ambulances are routinely transferred between stations and regions as part of a plan to ensure vehicle usage and availability is maximized. Ambulance #62499 was last serviced at 308,644 kilometres (km) on October 7th 2010. This ambulance was scheduled to be serviced every 5,000 km. or every 120 days.

Transmission Repair

An Ambulance ‘A’ Service Safety Inspection was completed on October 7, 2010 at Ucluelet Petro-Can with an odometer reading of 308,644 km. A note was made on the ‘A’ Service report by the Technician that the transmission torque convertor was slipping and a replacement torque convertor would be ordered to replace it. The Ucluelet Petro-Can indentified that the torque convertor was weak and advised the Unit Chief. The unit later ended up in Port Alberni where the torque convertor failed. The torque convertor was replaced at the Port Alberni Service Centre (Redfords) on October 13, 2010 at 308,838 km. For thoroughness, MIIT asked BCAS Service Centre Knighthill Automotive to pull the oil pan off the transmission for inspection. It was determined that the transmission was not broken and looked in excellent condition. In addition, Knighthill Automotive was asked to pull the cover off the differential and check its condition. It was determined by the technician to be in excellent condition.

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Tires

Ambulance #62499 was equipped with Bridgestone Blizzak tires which when new had 16/32nd of an inch of tread. At the time of the A Service the tires had 10/32nd and 11/32nd which is 2/32nd and 3/32nd above the BCAS PMP standard of 8/32nd, for winter driving. The Ministry of Transportation and Infrastructure CVIP standards identify that tires must be changed at 2/32nd and 3/32nd.

Ministry of Transportation and Infrastructure Post Crash Vehicle Inspection Report

In his report dated November 27, 2010, Motor Vehicle Inspector S. Jaques identified that the braking system/components, steering, suspension, tires, wheels and lighting on Ambulance #62499 were serviceable (Note: ‘serviceable’ in this context means functional). In addition, he summarized that the vehicle met the standards set out in the Motor Vehicle Act and Regulations.

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AMBULANCE: COMMUNICATION SYSTEM INFORMATION

The following communication devices were assigned to Ambulance #62499 and were present at time of the accident. The purpose of this section is to clarify the means of communication available and to define how and when it could have been used around the time of the accident.

Automatic Vehicle Location – VHF/cell

Automatic Vehicle Location (AVL) is supplied to the BCAS vehicle fleet through two

transmission mediums.

1. A VHF (Radio) system that is composed of leased lines owned by BCAS and managed by the BCAS Telecommunications Department.

2. CDMA/1X network (Cellular, same as a cell phone). The VHF system is the method that all data and voice had been delivered up until a

project to change the technology was initiated in 2007. Due to the expanding use of

data in the vehicles, BCAS Dispatch was experiencing static on the VHF voice line as

the congestion on the system increased.

At that time a decision was made to offload the data portion to a CDMA/1X network

similar to a cellular system. Some vehicles were kept on the VHF system where the

cellular reception was not sufficient for the load incurred.

Ambulance #62449 was equipped with a VHF system. The VHF system was set up

to send an AVL packet to Dispatch when the following conditions are met:

1. A button is pressed on the Mobile Data Transmitter (MDT) in the vehicle. Usually associated with a status change.

2. 100 miles have been travelled since the last AVL package (ping) was sent.

The BCAS Telecommunications department has confirmed that the first

communication with the vehicle’s MDT was at 01:39:04 on October 19, 2010. The

last GPS contact with the vehicle was at 04:49:25. The Telecommunications

department has confirmed that the last contact was generated from the AVL.

It is roughly 124 kilometres from Tofino to Port Alberni. The last GPS contact was at

the west end of Sproat Lake approximately 35 kilometres from Port Alberni. The

Telecommunications department feels this is the likely source of the last

communication with the vehicle and explains the void from 02:27:21 to 04:19:11.

All other AVL packets are explained by button presses.

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Cellular phone: Motorola KRZR # 250-720-5951

Telus cellular phone # 250-720-5951, assigned to station 136 Tofino, was used on two occasions on October 18, 2010:

1. October 18, 2010. 14:12, Port Alberni to Tofino Hospital, 250-725-3212. 2. October 18, 2010. 14:14, Port Alberni to Tofino Hospital, 250-725-3212.

No other calls were listed on the invoice from Telus. The equipment was not returned to BCAS Telecommunications.

Satellite phone: Iridium 9595A # 881651491387

Iridium # 881651491387 assigned to Station 136 Tofino, was recovered from Ambulance #62499 on October 19, 2010 and seized by WorkSafeBC under IR 2010117540067. The satellite phone was subsequently returned to BCAS on November 8, 2010 under IR 2010117540068. Globalstar (satellite phone plan provider) have confirmed that no calls were made from that phone for the period September 21, 2010 to October 20, 2010 and any and all calls made or received would appear on the invoice.

Radios – portable, mobile, CAD

Ambulance #62449 was equipped with the following radio communication equipment.

1. One mobile radio, CDM1550 LS+, was found on car and returned to BCAS Telecommunications.

2. Two hand-held portable radios, Motorola HT 1250, only one was found on car and it was returned to BCAS Telecommunications.

3. One CAD Head, CES Wireless Technologies TRK-240 was found on car and returned to BCAS Telecommunications.

Global Positioning System: Garmin Nuvi 255w

Ambulance #62499 had an assigned portable Garmin Nuvi 255w Global Positioning System. This unit was submerged for a number of hours and the distributors of the unit felt that the water would have destroyed the unit and any information it contained. The unit was returned to BCAS Telecommunications.

Pagers

The crewmembers each had a BCAS pager USAlert Nova, both pagers were returned to BC Telecommunications. The Unit Chief assigned Telus pager, Bravo Flex, was not returned to BCAS Telecommunications.

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INTERVIEWS

NOTE: for the protection of their privacy this publically available document has been severed of the personal identifiers of those interviewed and their statements.

Pages 25 – 42 have been severed

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CONTRIBUTING FACTORS AND PROBABLE CAUSE

This section defines the areas of enquiry for this investigation and provides an overview of the analysis and determination of each area in terms of contribution to or cause of the accident. Ambulance #62499 The condition of Ambulance #62499 was looked at very carefully to determine if the accident was contributed to or caused by mechanical defect. All service records and concerns were examined by Jim Fissel, Director, BCAS Fleet Operations, the ambulance underwent a Commercial Vehicle Inspection (CVSE), and mechanics at BCAS main service centre (Knighthill Automotive) followed up on recent work completed on Ambulance #62499. It has been determined by S. Jaques, Motor Vehicle Inspector, Ministry of Transportation and Infrastructure that the vehicle was fully serviceable and no unusual and problematic mechanical issues were found that would have in any way contributed to or caused this accident.

Employee Capacity at Time of Accident

Underlying Health Considerations

As this was a motor vehicle accident and the ambulance was in motion it is necessary to determine if the driver, Jo-Ann Fuller, had any health or medical issues at the time of the accident that may have impaired the ability to operate the vehicle safely and as a result contributed to or caused the accident. On the day of the accident, the bodies of Jo-Ann Fuller and Ivan Polivka were recovered from the ambulance and taken by the BC Coroners Service. At the time of this report the Coroner had not released a report on this accident. In an email dated April 4, 2011, David Ross, Occupational Safety Officer/Investigating Officer, Fatal and Serious Injury Investigations, WSBC Investigations Division and lead investigator for WSBC provided the following information; “The WorkSafeBC investigation has concluded that there were no factors found related to medical or toxicology that would have contributed to the accident”. Based on the information received from WSBC, MIIT has accepted that the driver’s health, medical or toxicology did not contribute to or cause this accident.

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Education/Training

In motor vehicle accidents, the training, skills and experience of the driver can contribute to an accident. In addition, the ability of workers to determine when it is unsafe to work is very important to worker safety. For this reason, the training records of both workers involved in this accident were examined by MIIT. Both crew members had received a full complement of safety education and training, including Emergency Vehicle Driver Regulation training. Jo-Ann Fuller had worked as a paramedic for 23 years and was well acquainted with operation of an ambulance. There is no indication that a lack of training, education or experience would have been a contributing factor or cause of this accident. Driving History

A historical pattern of poor driving behaviour can be an indicator of future poor driving. When reviewing the BCAS accident records database that predates either paramedic’s employment, no motor vehicle accident records were on file for either paramedic. A BCAS driver’s abstract was requested and reviewed; no accident history existed for either paramedic. Jo-Ann Fuller had no BCAS history of motor vehicle accidents thus no historical pattern that would suggest she was not a competent driver of an ambulance. There is no indication that Jo-Ann’s driving history was contributory to the accident.

Employment History

Attitude toward the work or the employer can often affect how workers approach their work, for this reason, a review of employee files was conducted and discussion with their Superintendent was undertaken. Both employees had good employment histories with no indications of problems, attitude concerns or behavioural patterns that would suggest any deficiency in approach to work. Falling Asleep or Fatigue

Being fatigued or overly tired and falling asleep while driving are common causes of motor vehicle accidents due to the potential for diminished ability to concentrate or focus, a reduction in reaction time, temporary loss of control, etc. A number of factors were taken into consideration when looking at this as a possible contributing factor or cause of the accident; i.e. the driver’s accident history, the configuration of the road, health or medications/alcohol, the amount of work within the last 24 hours, the time of the day, the age of the driver, witness statements, the conditions on the road (traffic, weather, etc.), amount of rest (within last 24 hours) prior to driving, and historical work pattern.

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Considerations: Jo-Ann Fuller was a seasoned paramedic but not at an age that would suggest

a predisposition to being overly fatigued; Jo-Ann had no health or toxicology that would have contributed; The call out occurred early in the morning (paged at approximately 01:35 –

not an uncommon response time for that station but still early am); Jo-Ann had worked a long call the day before (approximately 8.5 hours); Jo-Ann had approximately 5 hours of rest between her return from a call the

evening before and being paged for this call; Witnesses who saw Jo-Ann approximately an hour before the accident noted

she was alert and communicative, not overly tired; Witnesses who saw the ambulance on the road just prior to the accident did

not notice any erratic driving or speed; The section of highway just prior to and at the accident scene is very windy

and extensively signed indicating curves, oncoming traffic and need for reduced speed; and

Weather was lightly raining, relatively warm, and no fog. Under these circumstances it is reasonable to assume that Jo-Ann Fuller would experience some level of fatigue. However, with no witnesses to the actual accident or the ability to obtain a statement from anyone in the vehicle at the time of the accident, it is impossible to completely rule out, nor is it possible to confirm, the contribution of fatigue in this accident. Given all of the considerations above, MIIT cannot conclude that the accident was caused by Jo-Ann Fuller falling asleep or as a result of excessive fatigue.

External Factors

Weather Considerations

Conditions at the time of the accident: Temperature approximately 10 degrees; Light rain or mist – witnesses driving same road approximately the same

time, ambulance wipers on intermittent; No frost; and No fog.

MIIT has found no indication that the weather conditions were the cause or contributed to the accident.

Road Condition and Configuration

The road was wet consistent with a light rain or mist, the temperature was such that frost or icy surface was not present, the condition of road surface appeared to be clear of any rocks or debris and aside from some surface marking from rocks and debris falling from the adjacent cliff, the road was smooth with no pot holes.

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This is an area of Highway #4 where the road is at its narrowest and lack of shoulder created a significantly reduced margin for error. MIIT has found no indication that the road condition or configuration caused the accident.

Distraction

There were indications from the road surface (dimpled and worn) that rocks and/or debris has fallen down from the cliff. We received information from witnesses who frequent this highway that animals are routinely on the roads, on-coming traffic with varying beam height due to angle of the road and there is intrusion of vehicles into the on-coming lane. Given that there is no physical evidence or direct witness to the accident, this is impossible to confirm. MIIT has found no indication that any of these areas of possible distraction took place or were present at the time of the accident.

Speed

Excessive speed, especially on narrow, windy roads is known to contribute to motor vehicle accidents. The Collision Analyst Investigation Report makes no reference to the speed of the ambulance at the time of the accident. Corporal K. Ferguson stated that his scene examination found no tire marks on the roadway surface. Testimony by community members who saw the 136K1N just prior to the accident scene indicated that they did not observe any erratic driving or excessive speed. There is no indication that excessive speed was the cause or contributory to the accident.

Visibility

Poor visibility is known to be contributory to accidents. The Collision Analyst Investigation Report makes no specific reference to the visibility at the time of the accident. Corporal Ken Ferguson[ did reference Environment Canada Reports for that day that suggested to him that the roadway was wet from fog. Testimony by community members who saw the 136K1N just prior to the accident scene indicated that there was no fog and only light rain. One community member and Ambulance #62499 had wipers set on intermittent. There is no indication that poor visibility was the cause or contributory to the accident.

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CONCLUSION - FINDINGS

Throughout the investigation it has been the goal of the MIIT to be as thorough as possible and to expose anything that may have contributed to or have caused the accident. The absence of survivors or any witnesses to the actual accident and the inability to retrieve information from the vehicle’s tachograph has greatly hampered that effort. In addition, although some information has been received from WSBC, the MIIT did not have access to the WSBC report or the Coroner’s Report. The conclusion and findings of MIIT are therefore based on the information it had available to it. In the course of the investigation concerns were raised related to the lack of a nurse escort. BCAS policy provides specific language around assessments of patients and the need for escorts. 136K1N was directed by dispatch to conduct a risk assessment at the hospital to determine if 136K1N felt comfortable or safe doing the call. Although there was no direct feedback to dispatch on the assessment, 136K1N assessed the patient and proceeded with the call without escort. The MIIT believes that the actual cause of the accident will never be ascertained – no clear cause could be found. It is the belief of MIIT that a combination of factors may have contributed to this accident: Ambulance #62499 was returning from a very early morning call that started

with a page at 01:30. The driver of the vehicle had undertaken a long transfer on the afternoon of the

day before and had cleared the station to return home five hours before being awakened.

The opportunity for a significant distraction to have played a role, i.e. animals on the road, falling rock/debris from cliff on the other side of road, or eastbound truck/vehicle traffic turning wide into the westbound lane.

Most significantly, regardless of why Ambulance #62499 deviated from the line of travel, the configuration of that section of highway (narrow lane, no shoulder and the height and shape of the roadside barrier) created a situation where the margin for error was very small particularly with a vehicle the size of the ambulance. Based on the collective driving experience of MIIT members, ordinarily when a driver momentarily deviates from the centre of the lane, the road width and existence of a road shoulder, often with a rumble strip, affords the driver an opportunity and the available space in which to compensate. Such was not the case on this section of Highway #4.

The MIIT feels it appropriate to focus on two additional issues. Although these are not believed to have caused or contributed to the accident in any way, they certainly are significant in relation to the outcome or consequences of the accident.

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1. Ivan Polivka was confirmed to be in the rear of the ambulance and was not secured by any restraints or seat belts. Although the MIIT did not have reports related to cause of death, it is the belief of MIIT that had Ivan been secured at the time of this accident, it may have increased the percentage of his survivability of this accident.

2. The height and configuration of the road side barrier significantly

contributed to the vehicle climbing and going over the bin wall. It is the belief of the MIIT that, in all likelihood, had the now commonly used, newer style, pre-formed interlocking 0.69 metre high concrete road barriers been in place instead of the existing barrier (0.37 metre high), the ambulance may have been prevented from leaving the road.

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RECOMMENDATIONS

1. BCAS bring to the attention of the Ministry of Transportation and Infrastructure the role of that section of Highway #4 played in this event, and to encourage the Ministry of Transportation and Infrastructure to ensure the factors which contributed to this event are addressed.

2. Review and update if necessary current BCAS policy and practice related to

employees and/or non-BCAS employees riding in the patient compartment of the ambulance while not secured or seat belted. Define clear criteria related to when seat belt use can be modified based on patient safety and patient care.

3. Ensure any existing or new policy and direction on seat belt use while in the rear of the ambulance is effectively communicated to all EHSC staff, including the expectations of BCAS related to compliance with its policy.

4. BCAS review of its policies related to the appropriate provision of escorts by Health Authorities.

5. BCAS raise the awareness of BCAS personal of the hazards and risks associated with driving on a) that section of Highway #4 and b) other known similar sections of highways throughout the province for those who would routinely travel those sections.

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