Case Study
Incident Investigation
This case involves a carbon monoxide release in a multi-family residence, originating near a gas-powered water heater and resulting in injury. The plaintiffs alleged that a product defect in the water heater was the root cause of the incident. S-E-A was retained on behalf of the water heater manufacturer to investigate the source of the carbon monoxide release and evaluate the claims of product defect.
Assigned Task:
S-E-A was asked to perform a forensic investigation of the home, the water heater and all its connections to determine the cause of the gas release.
To perform the analysis, S-E-A took the following steps:
- Took Matterport laser scans of the home and the water heater to preserve the evidence, (See image below) which would be used later for further analysis.
- Investigated the water heater and its connections.
- Investigated the structure and building envelope.
- Reviewed the products literature, product alarm codes, service records, building codes, operation manuals, and contract documents.
Analysis:
- Utilizing the scan data, S-E-A’s Imaging Sciences team used their “gas tracking software” to produce a visual map of the CO travel path.
- Analyzed the physical cause of CO release and spread.
- Determined if faulty design, construction, or maintenance practices contributed to the incident.
Evidence was evaluated resulting in the following findings:
- The water heater operated as intended until external factors (improper condensate drain slope and freezing) led to failure.
- Installation of the drain system was found to not meet standards. The improper slope of the drainpipe caused water to be trapped in the drain system. The water then froze because there was no heat in the boiler room (construction design defect). The expansion of the water caused a separation in the exhaust discharge piping – thus a release of CO into the home.
- S-E-A discovered several unsealed penetrations in the boiler room that were in violation of mechanical and building codes. This allowed a path for CO to travel throughout the home.
- S-E-A discovered that alarm history was ignored: CO detector alarms were dismissed, silenced, and the detector was ultimately removed by management — a critical misstep in mitigating injury.
Peter McClellan, P.E., CFEI, LEED AP
Conclusion & Outcome:
S-E-A’s engineering analysis, combined with our Imaging Sciences Team’s 3D mapping of CO migration demonstrated that the failure originated from improper installation and environmental conditions, not from any defect in the manufactured water heater itself.
Our client reached a favorable resolution based on these findings, removing them from primary liability in the case. The evidence strongly suggested the building’s design and management practices played the more direct role in endangering residents.