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2006 Minato Ward elevator accident

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The Minato Ward 2006 elevator accident was an incident in June 2006 which shook Japanese public confidence in the safety of elevators around the country. In June 2006, in Minato, Tokyo, a 16-year-old high school student was killed by an elevator not maintained by SEC Elevator Co Ltd but of another elevator maintenance company. He was backing out of it with his bicycle when the elevator suddenly rose with the doors still open, causing asphyxiation. Investigations began relating to this fatality.

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In the process of this investigation, elevator safety in Japan came under question, with media attention focused on Schindler Group, the Swiss-based elevator manufacturer. Of the 8,800 Schindler elevators installed in Japan, 85 have trapped people.

Following the incident, the Minato Ward public housing corporation replaced all five Schindler elevators in the condominium with elevators from another manufacturer.

Responsibility

Elevator maintenance had been carried out by SEC Elevator in 2005, and by Japan Elevator Corporation from 2006 until the time of the accident, not by the manufacturer. The International Herald Tribune and Asahi Shimbun reported on June 14 that "Loose bolts and worn brake pads, evidence of poor maintenance, likely played a central role in the elevator accident". In the article it can also be read that "it is the responsibility of the maintenance company to ensure that such bolts are tightly fastened".

Schindler pointed out that the maintenance of the elevator was carried out by a non-affiliated maintenance company and that the company does not have an indication of a product design mistake so far. However, Tokyo Metropolitan Police concluded that both Schindler and maintenance company are responsible for the accident. Six people had been reported to have been prosecuted. Schindler, Minato Ward public housing corporation, and the Japanese elevator maintenance company, SEC, were publicly criticized for having displayed an evasive attitude toward the Japanese police and the condominiums' inhabitants. They did not respond to or attend any public meetings for the first 8 days, although they claimed to have fully cooperated with the investigation.

Progress of accident investigation

  • June 14, 2006. The International Herald Tribune (Herald Asahi) reports that "Loose bolts and worn brake pads, evidence of poor maintenance, likely played a central role in the elevator accident." ... "It is the responsibility of the maintenance company to ensure that such bolts are tightly fastened."
  • June 14, 2006. Investigations reveal 6 cases in Japan where the elevator moved with the doors still open. Manufactured between 1997-1998, they used the same circuit board model which is now being investigated by Schindler. In the Chiba case, Schindler is still maintaining the elevator in question. Questions about the origins of the defect and why it took 7 years for some of them to fail have been raised, but Schindler Elevator KK's head Ken Smith claims that it might be PCB that has deteriorated. The elevator has had additional anti-upward safety devices installed.
  • June 15, 2006. According to the Mainichi Newspaper, an employee of SEC testified to the police that he did not know how to adjust the brake of the "fatal" elevator and that he just left it as it was.
  • June 16, 2006. Schindler has admitted that a software problem caused the problem with several elevators in Japan. Elevators manufactured between 1991-93 are affected, although Schindler claims that this faulty code was not a material safety risk. The problem is elevator doors could open 0.5 seconds after the elevator starts moving. When the door opens, the elevator keeps moving and do not halt. Schindler would have upgraded the software code for the affected elevators by the end of June 17. However, this was not a factor in the Minato Ward accident which was still under investigation. On NHK 9 O'Clock News Schindler K.K. representative said that the programming error was detected and fixed for a number of elevators of the same model some time ago. However some service workers may have unwittingly gone and reprogrammed them again with the old codes during maintenance and this led to the malfunctions. Initially, 9 elevators were identified to have the problem, but the list later expanded to 52.
  • June 17, 2006. NHK reports that a problem in the brake has been found in the Minato elevator as replacing the brake yielded no operational problems. The motor was confirmed to be off when the elevator killed Hirosuke Ichiwaka. Experts have said (as quoted in the Yomiuri source at the end of this paragraph) if the motor was on, the boy would have received much more than bruising. Police are still investigating what caused the brake failure.
  • June 18, 2006. NHK has reported that SEC, the independent company in charge of maintaining the Schindler elevator at Minato Ward, had passed an inspection of the elevator in question just 9 days before the accident. SEC had said that all components including the brakes were working properly.
  • June 22, 2006. Minato Ward had confirmed that it will be replacing 2 of the Schindler Elevators (1 which killed 16 year old Ichikawa Hirosuke) to Mitsubishi elevators. The cost of replacement will be 168,000,000 yen (approx. US$1.46 Million).
  • June 22, 2006. Kyodo News reports: "Police suspect a Japanese maintenance company for Schindler elevators in a Tokyo apartment building had failed to follow checkup manuals before a fatal accident on June 3 in one of the units, investigation sources said Thursday." (...) "The police suspect some of the checks by SEC Elevator Co. on the elevator's brake system were insufficient against the checkup manuals provided by the maintenance company and a public housing corporation affiliated with the Minato Ward office, the sources said. The police believe a brake malfunction was one of causes of the accident which killed 16-year-old Hirosuke Ichikawa at the building in Minato Ward."
  • July 5, 2006. More Schindler door problems come to light: According to the Japan Elevator Association, the incidence of accidents in which passengers are trapped inside elevators made by the five major elevator manufacturers is on average 0.15 percent per month. However, in the case of those made by Schindler, the figure ranges from 0.4 percent to slightly less than 0.5 percent—about three times higher than average. Unfortunately the Japan Elevator Association data did not distinguish custom built elevators from commodity elevators. Custom built elevators have tend to have a higher defect rate. Elevator maintenance companies like Schindler, with a higher proportion of custom elevators, will have higher entrapment rates.
  • August 14, 2006. On NHK's News Watch 9, it was revealed that the elevator which killed Ichikawa Horosuke had anomalies in its brakes that did not relate to worn out pads. When tests were conducted, it showed that the disc brake was using 20% less current than other brakes of the same model.
  • November 20, 2006. The 'deadly' Schindler elevator that killed Ichikawa has been replaced with a new Mitsubishi Elevator (according to http://search.japantimes.co.jp/cgi-bin/nn20061121a8.html). The mayor of Minato Ward has test-ridden the elevator and residents are reporting a much smoother ride. For the past few months, workers have been working around the clock, replacing the elevator in record time. The other elevator will be replaced by February.
  • Wider concern

    Public concern over the Minato Ward case has not been limited merely to Schindler elevators. The Asia Times Online reports that in response to a flood of inquiries from customers, including building owners, the third-largest domestic elevator company, Toshiba Elevator and Building Systems Corp. is offering free inspections of their elevators, while Mitsubishi Electric Corp., the leading firm, and Hitachi Ltd, which is the second-largest, are responding to requests on a case-by-case basis. A recent Japanese survey shows that 65% of the students interviewed are uncomfortable with elevators following the Minato incident.

    In Hong Kong, following the Minato incident, many news agencies are drawing the similarities between the Minato case and the 2002 Fanling Hong Kong case. Thus, Hong Kong's Public Housing Authority has been questioned about the 33 public estates with Schindler elevators. The Housing Authority has said that all of its elevators are maintained by the original manufacturer (in Hong Kong's case, by "Jardine Schindler", a subsidiary of Jardine Matheson) and all elevators are inspected fully once every week. In comparison, Hong Kong law requires a full annual examination every year, load testing every 5 years, and an inspection every month. Some buildings have inspections every 2 weeks.

    On July 20, 2006, it was reported by Asahi, one of Japan's largest newspapers, that an increasing number of software problems have been spotted, leading to 113 elevators requiring a software replacement (as of July 20) - Source: http://www.asahi.com/national/update/0720/TKY200607200560.html.

    Multiple accidents involving Schindler products have continued to happen in Japan. See Schindler-related accidents and controversies

    References

    2006 Minato Ward elevator accident Wikipedia