Fatal Columbia Icefield Crash Inquiry Finds Brake Failures And Gaps In Maintenance

A newly released fatality inquiry report has identified brake failure, unaddressed maintenance concerns and travelling downhill in neutral as contributing factors in a July 2020 tour bus rollover at the Columbia Icefield that killed three people.

The 13-page report, written by Alberta Court of Justice Justice V.H. Myers and released publicly on Oct. 5, details the mechanical failures, maintenance concerns and operating conditions surrounding the crash.

The July 18, 2020, crash killed Dionne Durocher, 24, of North Battleford, Sask., Griva Patel, 28, of Edmonton, and Kamleshbai Patel, 58, who was visiting Alberta.

The vehicle, operated by Brewster Inc., rolled down a rocky embankment after losing control on the road leading to the glacier. Multiple passengers suffered serious injuries.

The inquiry examined the circumstances surrounding the crash, including the vehicle's mechanical condition, maintenance records and operating procedures.

What Investigators Found

According to the report, 24 people were aboard the Ice Explorer when it began descending the lateral moraine, a steep slope beside the Athabasca Glacier.

Investigators determined the vehicle was in neutral at or near the top of the hill, preventing the driver from using engine power to control its speed.

The bus accelerated to approximately 49 kilometres an hour, well above the 14 km/h maximum speed possible in fourth gear.

The driver attempted to brake, but worn braking components prevented the system from providing enough stopping power.

The steepness of the road also contributed to the crash. The section where the vehicle accelerated had a grade of approximately 40 percent, exceeding the manufacturer's specified maximum of 36 percent.

The vehicle eventually rolled, ejecting passengers through its windows and other openings.

What Maintenance Records Revealed

One of the inquiry's findings centred on maintenance concerns raised five days before the accident.

On July 13, 2020, the driver reported problems with the vehicle's brakes, including a request to have the slack adjusters inspected.

Slack adjusters are components of the braking system that help control how the brakes engage.

The report found no credible evidence that the concerns were ever addressed.

"The court concludes the braking system was not inspected or repaired," Myers wrote.

The inquiry also found that all three mechanics working on site were relatively inexperienced. Two interviewed during the investigation were unfamiliar with the Ice Explorer's mechanical systems.

Although the vehicle had reportedly undergone a 1,000-hour inspection shortly before the accident, the inspection report was undated and did not identify which vehicle had been inspected.

The court found the records insufficient to establish that the braking system had been properly inspected.

Inquiry Highlights Lack Of Seatbelts

The inquiry also identified the absence of passenger seatbelts as a contributing factor in the fatalities.

At the time of the crash, Ice Explorers were not required to have passenger seatbelts under the regulations applicable to the vehicles.

The report found that passengers were thrown from the bus as it rolled down the embankment.

"The lack of seat belts allowed the deceased and survivors to be ejected from the Ice Explorer onto the rocky landscape and undoubtedly led to more severe injuries and death," Myers wrote.

What The Inquiry Recommends

The fatality inquiry made four recommendations focused on improving maintenance, inspections and mechanic training.

These included requiring detailed inspection reports identifying the work completed on each vehicle, with copies available to drivers.

The court also recommended reviewing the company's three-year, 3,000-hour inspection procedures with Alberta occupational health and safety and transportation authorities.

Another recommendation called for vehicles with serious steering or braking defects to be immediately taken out of service until repairs were completed and signed off by both a mechanic and supervisor.

The final recommendation called for additional training for mechanics working on Ice Explorers, particularly on their braking and steering systems.

The inquiry did not make additional recommendations concerning seatbelts, noting that they had already been installed, or gear selection procedures, which the company had revised.

What Has Changed Since The Accident?

In an Oct. 5 written response to the inquiry, Pursuit Attractions and Hospitality, Inc., the parent company of Brewster, accepted all four recommendations.

The company said it suspended Columbia Icefield operations for more than 10 months following the crash while reviewing its safety procedures.

Among the changes, Pursuit reported spending $2.7 million to install passenger seatbelts across its Ice Explorer fleet.

The company also introduced a maximum road grade threshold of 36 percent, expanded driver training, implemented new maintenance tracking procedures and installed an automatic braking system on all Ice Explorers.

Pursuit said it now requires each vehicle to carry a current monthly inspection report. Vehicles cannot depart on tours if that report is missing or outdated.

The company also implemented an electronic maintenance work order system in November 2020, requiring work to be documented and overseen by a supervisor.

Pursuit says it has already addressed three of the four recommendations and is developing a Heavy Duty Mechanic Training and Competency Program to address the fourth.

The program will include minimum qualifications, equipment-specific training, practical assessments and annual competency reviews. It will also require both mechanic and supervisor approval before vehicles with identified braking or steering problems return to service.

Pursuit did not provide a completion date for the program in its response.

The Alberta government has also requested responses from the ministries responsible for workplace safety and transportation regarding the recommendations involving inspection procedures and mechanic training.

Responses are voluntary. The government says it will publicly identify any organizations or ministries that have not responded by Feb. 5, 2027.

While a public fatality inquiry does not determine legal responsibility for a death, its findings and recommendations are intended to help prevent similar tragedies.