Human error 'clearest contributing factor' in deadly Cleveland Dam incident: preliminary report

A preliminary report has found human error was the "clearest contributing factor" in a deadly incident last week at the Cleveland Dam in North Vancouver, B.C., the regional district said Thursday.

Two men, a father and son, were killed downstream when the spillway gate opened unexpectedly during maintenance on Oct. 1, releasinga freezing torrent of water into the Capilano River.

"While the review continues, we can now confirm that the clearest contributing factor was human error related to programming of the control system for the spillway gate at the Cleveland Dam," Metro Vancouver commissioner Jerry Dobrovolny said in a statement.

"Metro Vancouver takes responsibility for this mistake and our deepest sympathies go out to those affected by the tragic loss of life."

The man, who was an artist, and his son, 27, were among fiveanglers who were swept away by the gush of water after the dam opened without publicwarning. The father's body was discovered later that day, but the remains of hisson have not been found.

The other three anglersescaped the river on their ownor were rescued.

The river had risen by more than threemetres in a matter of minutes, surging through the popular fishing spot. One witness who was having lunch on a viewing platform over the water said the scene of fishermen scrambling for the banks was like "all hell" breaking loose.

WATCH |Witness recounts watching torrent of water rush down the Capilano River:

Witness recounts watching torrent of water rush down the Capilano River

4 years ago

Duration 1:07

'Sounds like a thunderstorm': William Joseph recorded video from the shore as water from the Cleveland Dam rushed down the river.

Alarm idea previously nixed

The report's findings come amid calls for Metro Vancouver to make the dam safer.There is no siren or alarm system to warn peopleif the dam malfunctions.

Such a warning system was never installed because of concerns the noise would annoyresidents in the Glenmore and Grouse Woods neighbourhoodsless than 400 metres away, according to engineering reports from the early 2000s.

"That's ridiculous," said Mike Hanafin, a hiker who saw the water surge and anglers scramble from a viewing platform above the river.

Hanafin said he wants to seewarning sirens strategically placed throughout the canyonthat wouldsound if the dam wereunexpectedly opened,rather than for controlled releases. He said a siren likely could have prevented the tragedy last week.

"Ifit annoys local residents once every 20 years, that's not a big price to pay," he said.

Geoff Kershaw, who regularly fishes at the Capilano River, said an alarm would help, but more should be done.

"There has to be some fail-safes in place that would at least require some form of human intervention before the dam is ever opened that quickly or that wide," he said.

History of malfunction

The dam, built in 1954, has a history of malfunctioning. Inspection reports from WorkSafeBC detailtwo errors that left people in danger in 2002.

In one instance that year, four fishermen were left stranded on a shrinking island in the middle of the river after the level of the waterway suddenly rose by more than a metre. In the other, a valve controlling the dam's gate opened by mistake whilea film crew was working directly below. TheWorkers' Compensation Board said the crewcould have been killed.

On Thursday, Metro Vancouver said the 2002 errors happened while the district was in the process of upgrading the spillway gate.The gate was upgraded from the oldmechanical system to a new, fully automated control system later that year.

Dobrovolny said the inadvertent openingthis month was the first since the upgrade.

The district said Thursday a formal public safety assessment of the dam was finished earlier this year, taking into consideration the hazards that come withpeople using the river downstream. The statement said thereviewfound the dam "demonstrated consistency with industry best practices."