The wall of water that swept at least five people along the Capilano River last week, killing at least one, was just one of a series of major torrents released by Metro Vancouver’s Cleveland Dam over the years, some of them deadly.

And at least one order to improve safety downstream from the dam by adding alarms to warn boaters, hikers and fishermen, dating back to 2002, appears to have not been implemented almost two decades later, an investigation by CTV News shows.

“My first reaction was: Again?” said Ken Ashley, the head of the BCIT Rivers Institute, who used to work for Metro Vancouver as an engineer in and around the Cleveland Dam.

“Something went seriously wrong. It shouldn’t have happened, but it did. What’s unusual is that it’s happened in the past and it hasn’t been corrected."

The sudden rising of the Capilano River levels is sometimes written off as natural behaviour. But it often has as much to do with water being released from the Cleveland Dam, a few kilometers upstream. The dam was built in 1956, using a device called a “drum gate” to control water flow.

The river suddenly surged in 1975, taking with it a nine-year-old girl, Jennifer Holtzman, newspaper records show. Her brother survived, telling his family about how the waters inexplicably changed.

Her family told CTV News they were too broken up to discuss the death, 45 years later. But they wanted her to be remembered as a wonderful daughter who brightened every room she was in and is still missed. Her father says he called for signs and alarms even then.

Signs were installed, but not alarms. In 1997, Squamish Coun. Wilson Williams said the only warning he heard was a sudden roar. He saw a rising blackness that, in the night, he struggled to identify as water.

“I ran for shore, ran for dear life, got swept out about 12 feet, was able to grab onto a rock and pull myself to shore,” Williams recalled.

He says he asked Metro Vancouver whether something had changed at the dam, and recalls he was told they were doing maintenance.

“Old-timers, other fishermen, they’ve had the same experience as me,” he said.

In 2001, records show another fisherman was stuck in the river's sudden rise. But it seemed when four fishermen were stranded on what was suddenly an island, things would change.

A WorksafeBC report from that year describes a failure of the dam as a “butterfly valve that controls the operation of the drum gate that inadvertently dropped open.”

The agency made several orders to the dam operator, Metro Vancouver, including “conducting a risk assessment to identify all hazards and levels of risk that each hazard presents regarding uncontrolled and/or controlled releases of water from the Cleveland Dam.”

It also ordered the dam operators to “develop, implement and enforce written policy and procedures designed to reduce or eliminate the risk to workers and the public from hazards identified in the risk assessment. These shall include but are not limited to: spillway gate lockout, access to the riverway by workers where lockout is not required, mancheck systems, emergency rescue and evacuation, public warning signage, and warning alarms.”

On Friday, Metro Vancouver CAO Jerry Dobrovolny confirmed that a problem occurred during maintenance of the dam, and that no such alarms are in place.

“There’s no publicly facing alarms on the dam. No sirens, flashing lights, anything like that,” he said.

It’s not clear why that element of the order doesn’t appear to be followed. Metro Vancouver didn’t answer questions from CTV News Tuesday, and WorkSafeBC said the event was long enough ago that its staff had to do further inquiries.

A deadline was set in the Worksafe BC inspection report for the risk assessment, but not for the other instructions, including for the alarms.

Alarms are standard on BC Hydro dams, and that would be one measure to ensure the dam has a backup to avoid becoming dangerous if there’s another error, said Ashley.

He says the unusual design of the dam, where the drum gate floats on a reservoir, means that if anything goes wrong, the dam falls open, sending water flooding out. Mechanical gates that operate like drawbridges on other dams are much more precise to operate, with less chance something will go wrong, he said.

“It’s not fail-safe, because it’s failed. And it’s not safe-fail, because it failed and caused fatalities. The whole design requires a rethink,” Ashley said.

The dam is inspected regularly by provincial regulators, who describe its “consequence classification” as “extreme,” because of the potential consequences of failure of loss of life, environment and cultural values, and infrastructure and economics.

The last audit was in 2015, and the next audit was scheduled for Oct. 28, 2020 – just weeks away.