The party bus involved in a fatal 2016 accident in Vancouver had a “long history of door malfunctions,” according to a BC Coroners Service report into the death released Tuesday.
That conclusion has prompted new recommendations from the agency urging tighter regulation of inspections and documentation of repairs for the vehicles.
Chelsea Lynn Mist James of Langley was killed instantly when she fell out the door of a moving party bus at Burrard and West Hastings streets on Jan. 9, 2016.
The driver had just made a left turn, causing her to fall into the stairwell; when she struck the door, it opened and James fell out, the report concludes.
According to the coroner’s report, the day of the accident two passengers had attempted to get on the bus while it was moving, and the doors opened while in motion.
“When that driver started that bus trip, he should have pulled it over and said, ‘Hey, we’re not moving. This isn’t safe,'” said Chelsea’s mother Shelly James.
“I think its a kick in the head again, or a kick in the gut — it stabs the heart all over again, because it was a preventable accident.”
The coroner’s report also found the 2008 Ford bus had a documented history of problems with the door.
Those included problems with the door not opening, documented in a March 2013 inspection, as well as an April 2014 inspection.
The coroner’s report noted that in both cases the Commercial Vehicle and Safety Enforcement Branch (CVSE) ordered repairs, but that proofs of the repairs were never provided to the agency and “it is unknown whether the violations were addressed.”
The report also cited records from a designated inspection facility (DIF) which said repairs were conducted on the main passenger door in 2011 and 2013.
In 2013, the mechanic twice noted that the door wasn’t working properly and recommended the party bus be taken to a body shop.
“But there is no documentation to show that the suggested repairs were ever performed,” states the coroners report. “Despite these recommendations, the limousine was given a passing grade.”
A post-crash CVSE inspection of the party bus found problems with its pneumatic door pressure system, including misalignment due to previous repairs, according to the report.
An engineer’s report commissioned by Vancouver police found the door could be opened while the vehicle was in motion due to low pneumatic pressure and a non-functioning locking mechanism, the report adds.
“After Chelsea died through that bus I called up CVSE, they had no clue where that bus is,” her mother told Global News.
“The company was allowed to sell it to another company.”
The coroners report says the vehicle’s new owner has since installed a new electric closing mechanism, and has had no documented issues since.
The coroner’s report concludes by recommending regulations be changed to better track documented problems with commercial vehicles.
It recommends creating a CVSE tracking system to ensure that the orders it issues and subsequent compliance are documented, and that there is enforcement when the work is not done.
It also recommends a better quality management process for designated inspection facilities to ensure work is up to standards.
Further, the report recommends that the province consider revising Commercial Vehicle Inspection Reports to include documentation of all vehicle repairs.
Shelly James said tracking repairs is a good start, but she’s still frustrated with the lack of serious consequences for anyone involved in the fatal accident.
“Talk is cheap. Let’s see some action,” she said.
The recommendations come amid tougher new rules for party bus operators after several incidents and deaths in recent years.
Under the new regulations, party buses found to be breaking the rules could be subject to $50,000 fines.
They also must have a safety monitor aboard who is trained in first aid and the use of naloxone if there are unaccompanied minors, while parents must sign consent forms for all youth aboard.
Open containers of alcohol remain illegal in all vehicles.