Theme park tragedies, safety management systems and the role of the regulator

There has been a number of recent theme park Events at the time of writing this.  Three examples are:

Alton Towers, UK  (June 2016)

Sixteen people were injured when an occupied carriage of a roller coaster ride collided with a stationary empty carriage on the tracks. Two young people lost legs in the impact.  The regulator imposed a fine of £5,000,000 on the operator of the site apparently (according to the press) influenced by the fact that an engineer had said he felt under pressure to get the ride operating.

According to the Guardian news paper, a worker (presumably the engineer) manually overrode the computer system.

Dreamworld, Australia (October 2016) 

Four people were killed on the Thunder River Rapids ride when one carriage stopped and was hit by another one which was still travelling behind it.  One of the carriages flipped its occupants into the water.  Injury resulted both from immersion and from entanglement in the carriage drive mechanism.  Subsequent detailed investigation by the regulator resulted in a small number of Improvement Notices for unrelated matters.  The press saw the fact that the State Government subsequently passed an occupational manslaughter Act as significant.  Various people have told a legal firm about incidents they experienced at the park.

The Australian Broadcasting Corporation reports that “There were 111 serious ride incidents in Australia between 2001 and 2011, and a significant number may be attributed to inadequate training or operator error, according to Work Place Health and Safety.

The picture is of a similar ride at Legoland in the UK.  It shows, at the rear, a raft on the transfer conveyor, in front of that one that has just been conveyed into the unloading race (along which it is driven by two wooden-slatted side conveyors) and two rafts in the unloading/loading area.

Drayton Manor Theme Park, UK (May 2017)

An 11 year old girl died when she fell from the Splash Canyon water ride.  According to the Sun newspaper report Evha Jannath stood up to change seats and fell into the 5 feet deep water.  Eva tried to get back into the carriage but received no assistance and was eventually dragged under the wild water, where she “sustained blunt force chest trauma” and died.  Another parent told newspapers that some years before this her son had fallen in and been rescued by by-standers.  The mother of the boy had written to the theme park to tell them about this experience.  According to the Sun’s report “Health and safety inspectors are continuing their “important work”.

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In a way, these are just a random selection of the things that kill people on a regular basis, so why single them out for attention here?  One reason is that the victims are young members of the public out to enjoy themselves.  Dying or being severely mutilated in this situation is shocking – these events attract public and media attention as a consequence.  Given the public reaction, the regulator also finds itself in the spotlight.  In my view, these instances expose the underlying weakness of the regulatory system.  As examples, they are valuable illustrations of the points made in Chapters 11 (The Management of Risk) and 12 (Managing Technical Risks).

The standard regulatory approach to occupational safety is to impose responsibility on the person or people responsible for the management of the organisation.  This responsibility is stated in Acts and associated Regulations.  In my career I have regularly seen regulators tweaking the wording of these statements to make prosecutions easier to obtain, increasing the magnitude of fines and adding real people (including possible jail sentences) not just corporations to the target list.  Sometimes the reliance on the legal strategy escalates into industrial manslaughter Acts.  The first time you see it you’re impressed by their action.  Thereafter one can have a more jaded response – maybe they actually don’t know what else to do?  One could say the only strategy being followed by the regulator is to create a more easily wielded stick (that can do more damage) with which to beat the organisation.  If one stick does not make our intention clear, let’s make a bigger one.  No doubt, given the history of common law in this field, such legal instruments are inevitable.  It does happen, but only in a few distinct areas, that regulators specify the need for designs to be certified by professional engineers and registered with the regulator.  For example, pressure vessels, cranes, some amusement structures, high hazard industries and the like.

The more usual regulatory approach to public safety, on the other hand, is to set and enforce design, training and maintenance standards.  Governments try to ensure minimum standards of public safety by setting up authorities whose role is to oversee design standards of publicly used things, be they vehicles (cars, boats, aircraft) and routes (roads shipping channels, airways), electrical appliances and domestic electrical systems, the design of buildings and equipment/machinery used by the public (eg. lawn mowers, food processors), baby capsules, child car seats and the like.  These authorities have the power to approve standards, influence design etc. and the power to prevent sale, as well as the power to prosecute if unapproved devices are on sale.

Theme parks appear to fall somewhere between these two (i.e. occupational and public) approaches.  They include regulated amusement structures, but the fine detail of how different rides etc. are managed by the operator is evidently not something in which regulators are much involved and in my view it is not appropriate for them to be so.

I wish to make it clear that I have no intention here to cast doubt on the well meaning intentions of those whose business is the design and provision of ‘rides’ nor on the operators of theme parks.  Rather, my intention is to point out a practical way for the regulator to assist them to manage their risks.

The technical requirements of safety in such situations are not difficult for a specialist to understand, but are theme parks likely to be able to find or perhaps even afford such a person?  How do they know if the rides they buy are well designed?  If they are, are they advised of the critical maintenance and operating practices and, if so, are these remembered over the years?  In my experience, operators of plant seldom understand the design assumptions made by design engineers.  Operating practices are left to the operators to work out.  Maintenance practices are subject to the (regrettably) often limited understanding of maintenance trades people and are subject to the restrictions of maintenance budgets.  In all of this there is seldom, if ever, to be found a technically competent guiding light.

This guiding light must at least show an understanding of common law expectations.  If it did no-one would make statements such as “a significant number may be attributed to inadequate training or operator error, according to Work Place Health and Safety”.  Really?  Not at all to design or to maintenance?  I recall a common law statement along the lines of “a situation cannot be rendered safe by relying on the good behaviour of an attentive worker“. Also, I recall a common law expectation that where a fatality is possible (I would say the Likely Worst Consequence is one or more fatalities or their equivalent in untreatable injury) the best possible design must be made use of – not the best practical design.  The emphasis is, without a shadow of doubt, on design and that also therefore means on maintenance and renewal practices as the design ages, clearly not on the behaviour of operators, even though design does generally impose some restrictions on what operators can do or provide opportunities for them to do things in certain ways.  Design and operating method are inextricably interlinked.

All of these significant details are hard for designers to write into operating manuals and for any operating organisation to keep in mind as the years pass by and personnel come and go.  It is also not feasible for a regulator to keep their eye on these details for one industry, let alone for all industries.  Yet it remains true that the origin of major consequences is to be found in the smallest of details of design, maintenance, condition and operation.

So, if the regulator can’t assist here (how can they hold all that minutiae in their corporate memory?) and the problem is hard for the responsible organisation to understand and manage, what is the solution to the problem?

Any answer to a risk management problem must surely be one that sets up a long term systemic approach to the management of risk.  A systemic approach is described in the book.  It is more, much more, than the risk (or safety) management programme found in any one organisation.  It encompasses the whole community of similar organisations as well as those that provide equipment, services and supplies to them.

A systemic approach has been shown to work – as the book makes evident – so long as all players are engaged in an integrated effort and so long as the system has the goal of improving risk controls as a major emphasis in the operation of the industry.

A suitably designed self-managing system is better than a system of punishment for failure.  I can’t imagine what possible benefit to the management of an organisation a fine of £5,000,000 (just for example) is or sending a manager to jail for industrial manslaughter, except in the most extreme cases.  I can easily see this expense leading to a counter-productive reduction in operating costs (employment, training, maintenance, equipment renewal), which itself leads to an increase in risk.  Of what possible value is that?

A systemic approach requires organisation of the industry as a whole.  Imagine if it was a requirement for:

  1. All organisations to belong to a relevant industry association.  In this case, for example, a theme park operator industry association.  The system being managed is the whole of this industry.
  2. The industry association to act as a claims agent for workers’ compensation and if relevant (as in theme parks) also public liability claims.  The system then has the feedback pathway (claims information) so necessary in any control system.
  3. The industry association to help its members to implement effective risk management processes (containing all the little details that are so important) and of helping equipment suppliers to the industry to offer improved designs?  A small surcharge placed on claims costs or insurance premiums would provide the industry association with the resources needed to achieve this – specialists in various aspects of risk, reliability, human factors, training and so on and all directed at not just improving risk controls but also industry efficiency and the well being of employees.  The industry association influence extends to the design of equipment (it would influence equipment suppliers by assisting them to improve designs and encouraging members to buy approved designs), its installation and operation,  maintenance practices and the knowledge and skills of the people who work in the industry.
  4. The industry association to encourage or enforce (if necessary) adoption of their guidelines.  For example, the association could be permitted to raise its premiums for recalcitrant members or even expel them from the association, meaning effectively that they were no longer able to operate in that industry.  Any control system needs an effective means of exerting control over the system being managed.

Goodness me, this is sounding just like the German industry association role! There the industry association is made up of both businesses and the unions that work within them.  Government there retains its right to enforce legislative requirements developed a tripartite system, so nothing is taken from existing Government regulatory roles.

A positive and forward-looking role for Government is to set up such a role for industry associations.  It is not impossible for industry to organise itself in a similar manner without Government prompting, indeed the mining industry is seeing the benefits of doing this on an international scale,  but it is always the case that the community looks to Government for leadership and in this case Government can ensure that a proper control system exists and is maintained.

How satisfying it would be to see that leadership occur in the theme park industry, in which a unique combination of occupational and public safety concerns coincide.  Government could build a bridge between those two very differently regulated domains, in one of which (public safety) it already has a powerful and effective role and lead the way in the regulation of safety in general and occupational safety in particular.

 

 

2 Comments

  1. bcorden@optusnet.com.au

    Dear Derek,

    Tougher legislation with increased fines, jail sentences will not change the mindlessness. It will merely exacerbate the problem and certainly won’t reincarnate the deceased.
    The only parole for the bereaved is death or dementia yet following the DreamWorld disaster the major focus was cash flow getying the place open again.
    Many of these theme parks and golf courses are built on old rubbish dumps or tips and environmental approval to build housing developments and gated community projects is almost impossible after Love Canal in US during the 1950s.
    The total cost of risk is also disregarded, which is now reflected in the share price of Dreamworld’s parent company. It plummeted immediately following the fatalities with a loss of $140 million. A $5 million penalty is insignificant.
    Furthermore, the bigger stick will have an enormous impact on investigations and conceal the truth.

  2. Derek Viner (Post author)

    Interesting points, Bernard. It is worth noting though that share price fall affects share holders. A fine has a direct effect on operating profit and loss.

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